A Message - New Jersey Department of Health · he New Jersey Hospital Performance Report was first...

Welcome to the New Jersey 2011 Hospital Performance Report, the New Jersey Department ofHealth and Senior Services eighth annual report on the quality of care in New Jersey hospitals.

Improving patient safety and ensuring high quality health care are top priorities of the Department ofHealth and Senior Services. All of our licensed health care facilities strive every day to reducemedical errors and healthcare-associated infections (HAIs) and to ensure that every patient receivesthe highest standards of care. Educating consumers about the performance of the facilities where theyreceive care is equally important because it empowers them to make informed decisions.

Closely following the federal government’s yearly expansion of quality measures, the Department hasadded the following measures to this year’s report:D A Surgical Care Improvement Project (SCIP) measureD Three HAI measures:

l Catheter-Associated Urinary Tract Infection (CAUTI) l Two Surgical Site Infection (SSI) measures: SSI after Coronary Artery Bypass Graft

(CABG) Surgery, and SSI after Abdominal Hysterectomy

The report still contains the same measures for: D Recommended Care: heart attack, pneumonia, surgical care improvement project (SCIP) and

heart failure D 12 Patient Safety Indicators (PSI) mandated by law, and D HAI measure for Central Line-Associated Blood Stream Infection (CLABSI), also required by

legislation

All the measures in this report are based on scientific evidence and research performed at thenational level. The data is from 2010 except for the two new SSIs, which are based on 2009 data.

The Quality Improvement Advisory Committee (QIAC) is instrumental in developing this report andprovides guidance to the Department on quality initiatives. QIAC members, who are leaders fromthe New Jersey hospital industry and health care providers, volunteer their energy and skills to advisethe Department on high quality health care programs. These programs have helped position NewJersey in the forefront of other states.

For more data, consumer tips and other health care information, visit our web site atwww.nj.gov/health/hpr. Learn about: D How to prevent HAIs while in the hospital D What you can do before having surgery to help prevent medical errors, and D Tips on how to choose or locate a doctor in New Jersey

I hope you find the report useful. Please feel free to send us your feedback on the report or the website at [email protected].

A Message

For questions about this report, please contact:

Office of the Commissioner Health Care Quality Assessment (HCQA) New Jersey Department of Health and Senior Services P.O. Box 360 Trenton, New Jersey 08625-0360

You can also reach HCQA by phone at (800) 418-1397.

Find more information on our web site at www.nj.gov/health/hpr. The site allows you tochoose hospitals to compare by hospital name, condition or county. In addition to themeasures included in this report, the web site also includes mortality measures forCoronary Artery Bypass Graft (CABG) surgery; mortality for Inpatient Quality Indicators(IQIs) for heart attack, pneumonia, heart failure, and stroke; and scores for outpatientRecommended Care measures. The web site also contains an extensive list of resourcesand additional patient safety tips on how to prevent medical errors.

Portions of this report rely on material developed by the US Department of Health andHuman Services, Centers for Medicare and Medicaid Services, Centers for DiseaseControl and Prevention; the Agency for Healthcare Research and Quality, and the JointCommission.

Other reports produced by HCQA and found at the web site:

Cardiac Surgery in New JerseyInpatient Quality IndicatorsBariatric Surgery in New JerseyPrevention Quality IndicatorsPatient Safety IndicatorsHealthcare-Associated Infections

We would like to thank the following people for

their contributions to this report:

Cynthia Kirchner, Director, Quality Improvement

Emmanual Noggoh, Director

We would also like to thank the followingpeople for the graphic design, the editing

and the printing of this report:

Jan ApplebaumSue CarsonJames Wisniewski Markos Ezra

Priya Bhatia FoxLetitia Holloway-OwensJianping Huang

Juana JacksonMarcia JaffeAbate Mammo

Mary E. O’Dowd, MPHCommissionerDepartment of Health and Senior Services

From the Commissioner

Section 1: Using This Report. . . . . . . . . . 3

D Hospital Quality and Using ThisReport . . . . . . . . . . . . . . . . . . . . . 4How to use this report

D Guidelines to Understanding theDifferent Measure Sets . . . . . . . . . 6How to interpret the data for the different measures

Section 2: Recommended Care/Process of Care Measures . . . . . . . . . 7D Understanding and Using

Recommended Care Measures. . . . 8 Essential information to understanding and using these measures

D Importance of These Measures . . . 9 National data on the impact of these conditions

D Overall Scores . . . . . . . . . . . . . . . 10 Heart Attack, Pneumonia, Surgical Care Improvement and Heart Failure

D Basic Facts on Treating HeartAttacks . . . . . . . . . . . . . . . . . . . . 12 Treatment measures and health care information

D Heart Attack Treatment Scores . . 14 Overall Heart Attack ScoresAspirin at ArrivalAspirin at DischargeBeta Blocker at DischargeACE Inhibitor or ARB at DischargeSmoking Cessation AdvicePCI Within 90 Minutes

D Basic Facts on Treating Pneumonia. . . . . . . . . . . . . . . . . . 16Treatment measures and health care information

D Pneumonia Treatment Scores . . . 18 Overall Pneumonia ScoresPneumonia VaccinationInfluenza VaccinationAntibiotic TimingAntibiotic SelectionBlood Culture Before Initial AntibioticSmoking Cessation Advice

Table of Contents

D Basic Facts on Surgical CareImprovement . . . . . . . . . . . . . . . . 20 Treatment measures and health care information

D Surgical Care Improvement Scores . . . . . . . . . . . . . . . . . . . . 22Overall Surgical Care ScoresPreventive Antibiotic StartedPreventive Antibiotic StoppedAppropriate Antibiotic ReceivedSafe Hair RemovalUrinary Catheter RemovalTreatment Preventing Blood Clots OrderedTreatment Preventing Blood Clots ReceivedControlled Blood Sugar for Heart Surgery PatientsBeta Blocker Continued Before and After Surgery

D Basic Facts on Treating HeartFailure . . . . . . . . . . . . . . . . . . . . 26 Treatment measures and health care information

D Heart Failure Treatment Scores. . 28 Overall Heart Failure ScoresLeft Ventricular Systolic Function AssessmentACE Inhibitor or ARB at DischargeDischarge InstructionsSmoking Cessation Advice

D Statewide Scores Compared toNational Scores . . . . . . . . . . . . . . 30New Jersey Recommended Care scores compared to national scores

Section 3: Patient Safety Indicators (PSIs) . . . . . . . . . 31D Understanding and Using Patient

Safety Indicators . . . . . . . . . . . . . 32Essential information to understanding and using these measures

D Basic Facts on Patient SafetyIndicators . . . . . . . . . . . . . . . . . . 34Definitions and importance of measures

D Patient Safety Indicator Rates. . . 36New Jersey rates for 12 PSIs

D New Jersey Statewide PSI RatesCompared to National Rates . . . . 40New Jersey PSI rates compared to national rates

Table of Contents

Hospital Performance Report 20112

Section 4: Healthcare-Associated Infections (HAIs) . . . . . . . . . 41D Understanding Measures for

Healthcare-Associated Infections . . . . . . . . . . . . . . . . . . 42Essential information to understanding and using these measures

D Central Line-Associated BloodstreamInfections (CLABSI) Data . . . . . . . 48Ratios for CLABSI

D Catheter-Associated Urinary TractInfections (CAUTI) Data . . . . . . . . 50Ratios for CLABSI

D Overall Surgical Site Infections (SSI) Data . . . . . . . . . . . . . . . . . . 52Composite ratios for all SSIs

D Abdominal Hysterectomy SurgicalSite Infections Data. . . . . . . . . . . 54Ratios for Abdominal Hysterectomy SSIs

D Coronary Artery Bypass Graft (CABG)Surgical Site Infections Data . . . . 56Ratios for CABG SSIs

D Preventing Surgical Site Infections (SSI) . . . . . . . . . . . . . . 57Techniques to help prevent SSIs

D Preventing Central Line-AssociatedBloodstream Infections (CLABSI) . . . . . . . . . . . . . . . . . . . 58Techniques to help prevent CLABSI

D More About Catheter-AssociatedUrinary Tract Infections (CAUTI) and How to Prevent Them . . . . . . 59Information and techniques to help prevent CAUTI

D Handwashing Helps Prevent Infections . . . . . . . . . . . . . . . . . . 60Techniques for proper handwashing

Section 5: Consumer Information . . . . . 61 D Taking an Active Role in Your

Health Care . . . . . . . . . . . . . . . . . 62 Patient responsibilities for maintaining health and understanding treatment options

D Patient Safety Tips for Surgery . . 64 Questions to ask before surgery

D Finding a Doctor . . . . . . . . . . . . . 65What to look for in a doctor and web sites to

find one

D Health Information and Referral . . . . . . . . . . . . . . . . . . . . 66Health care resources

D Hospital Patients…Know Your Rights . . . . . . . . . . . . . 68 Patient rights in New Jersey

D Health Quality Oversight . . . . . . . 70Government regulatory supervision

D Filing a Complaint . . . . . . . . . . . . 71 How to file a hospital complaint

D Quality Improvement AdvisoryCommittee (QIAC) . . . . . . . . . . . . 72 Advisory committee on this report

Section 6: New Jersey General Acute Care Hospitals . . . . . . . . . . . 73

Section 1

Using This Report

D Hospital Quality and Using This Report

D Guidelines to Understanding the

Different Measure Sets

Usi

ng

This

Rep

ort

Hospital Quality Using This Report&he New Jersey Hospital Performance Report was firstcreated in 2004 to provide hospital quality informationto patients, their families, and health care professionals.Since then, the report has been published annually. The

information in this report is designed to help you choose ahospital and make other decisions about your healthcare.

Quality of care can have so many different meanings. In thisrepor t, quality of care is defined by using nationally

recognized standards of care that are measurable.

This year’s report is divided into six sections. This firstsection is an introduction to quality and how to use thereport, followed by three sections that contain data andexplanations showing how well each NJ hospital is doing inproviding quality care to their patients. The last twosections of the repor t provide important consumerinformation and a list of NJ hospitals.

T

What measures are in thereport?

The three different types of measuresets in this report identify the successor failure of different aspects ofquality hospital care.

Recommended CareThe first set of measures is calledrecommended care or process of

care measures. Recommended care

measures show how each hospitaltreats eligible patients with fourspecific conditions: heart attack,pneumonia, heart failure andpatients having surgery (also knownas the surgical care improvementproject, or SCIP). It examines thenumber of times a patient receivesthe correct care. Patients mustreceive the correct care in order tofully recover.

Recommended care measures weredeveloped by the federal agency,Centers for Medicare and Medicaid(CMS), and the Joint Commission,an independent, not-for-profitorganization, recognized nationwideas a sign of quality.

This year, there is one new measurefor SCIP, urinary catheter removal onthe first and second day after surgery.

The data for the recommended carein this report is for the year 2010. Seepages 7-30 for the data and basic factson recommended care.

Patient Safety Indicators (PSIs)The next data set in the reportfocuses on how well each hospital isproviding safe patient care by lookingat the number of medical errors perhospital that could have beenavoided. These measures are calledpatient safety indicators (PSIs).PSIs were developed nationally bythe federal Agency for HealthcareResearch and Quality (AHRQ), afterextensive research and analysis.

The report includes 12 PSIs

identified by New Jersey Statelegislation. The data for PSIs in thisreport is for the year 2010. See pages36-40 for the PSI data and pages 31-35 for basic facts on PSIs.

Healthcare-Associated Infections(HAIs)The third data set in this report is onhealthcare-associated infections (HAIs)in hospitals. HAIs are infections thatpatients get while staying in a hospital –infections they did not have beforebeing admitted. Knowing the numberand rate of infections at each hospitalhelps assess how well a hospital is doingin preventing HAIs.

There are many different kinds ofHAIs. Last year, we reported oncentral line-associated bloodstreaminfection (CLABSI), the first HAI to be


Section 1: Using This Report

If doctors make decisionson where a patient shouldget care, why should I lookat hospital performance?Many consumers want a doctor’srecommendation on hospitals.Frequently, people collect as muchinformation as possible to makeinformed decisions. This report willprovide some of that information.

Some people, however, focus on ahospital first and then choose adoctor who is affiliated with that

particular hospital. A doctor musthave privileges at a hospital to admitpatients. Your doctor may admitpatients to several hospitals.

If you are enrolled in a managed careplan, use this report to help reviewyour hospital network. Managed careinsurers usually offer several choicesof hospitals in an area.

Aren’t all doctors andhospitals the same?No. Hospitals differ in their specialtiesand expertise. Some are betterequipped than others to handledifferent conditions and levels of care.Not all hospitals have state approval toperform certain services. Hospitalsemploy doctors with differentspecialties, expertise and abilities.These differences will influence thequality of care that you receive.

Why should I care aboutquality?Hospitals differ in how well theyprovide appropriate care to patients.The quality of the care provided byyour doctor and hospital mayinfluence your health.

Why are there so manydifferent measures in thisreport?To determine a hospital’s quality ofcare, it is important that you look atdifferent aspects of care and fromdifferent angles. Individually, eachmeasure used in this report capturesonly one aspect of care. It isimportant to consider many differentmeasures to create a bigger picture ofthe quality of health care eachhospital delivers.

Can I use the informationin this report to drawconclusions about New Jersey hospitals?This report is not intended to beused alone. It is designed to provideimportant information to help youmake informed decisions. Use thisreport along with other informationin making decisions about hospitals.

What should I do with theinformation from this report?Ask your doctor questions. Beinformed. Use this report to gathermore information and makeinformed decisions about whichhospital is most appropriate for yourhealth care needs.

A Consumer Report 5

publicly reported in New Jersey. Thisyear, we have added three measures:

Catheter Associated Urinary TractInfection (CAUTI)

Surgical Site Infection (SSI) afterCoronary Artery Bypass Graft(CABG) Surgery

Surgical Site Infection (SSI) afterAbdominal Hysterectomy.

HAI measures were developed at thefederal level by the Centers for DiseaseControl and Prevention (CDC).

Data for the CLABSI and CAUTI

HAIs are for the year 2010. Data forthe SSI HAIs, CABG Surgery andAbdominal Hysterectomy are for theyear 2009 since they require a year tofollow-up with the results.

See pages 48-56 for the HAI data,pages 41-47 for basic facts on HAIs,and pages 57-60 for preventing HAIs.

Which hospitals areincluded?All New Jersey general acute carehospitals are included, along withone specialty hospital that treatsheart disease.


Guidelines to Understanding the Different Measure Sets

RecommendedCare

(Process of Care)

See pages 7-30

Patient SafetyIndicators (PSIs)

See pages 31-40

Healthcare-Associated

Infections (HAIs)

See pages 41-60

Higher Score is Better

Lower Rate is Better

Lower Ratio is Better

Type of Measure

These measures are national benchmarksbased on research that supports thatthese actions are the best care forpatients with the specific condition. Youwant this type of care; you want thescores to be high, showing hospitals aredelivering the correct care.

These measures show how manypatient safety errors occurred in eachhospital that could have potentially beenavoided. You don’t want the rate to behigh; you want it to be low, showingfewer errors.

These measures show the number ofinfections acquired by patients while inthe hospital. You don’t want the ratio tobe high; you want it to be low, showingfewer healthcare-associated infections.

How to Read Data Tables Explanation

This year’s report includes three different measure sets with different ways of reading theresults. The table below is intended to help you understand how to interpret the data.

Section 2

Recommended Care/Process of Care Measures

D Understanding and Using Recommended Care(Process of Care) Measures

D Importance of These Measures

D Overall Scores

D Basic Facts on Treating Heart Attacks

D Heart Attack Treatment Scores

D Basic Facts on Treating Pneumonia

D Pneumonia Treatment Scores

D Basic Facts on Surgical Care Improvement

D Surgical Care Improvement Scores

D Basic Facts on Treating Heart Failure

D Heart Failure Treatment Scores

D Statewide Scores Compared to National Scores

Rec

omm

ended

Care

/Pro

cess

of

Care

Mea

sure

s

Understanding Using Recommended Care (Process of Care)Measures

&ecommended Care Measures show how often eachhospital treats eligible patients with four commonconditions: heart attack, pneumonia, heart failure

and patients having surgery. These treatments have beenscientifically proven at the national level by the Centers for

Medicare and Medicaid Services (CMS) and the JointCommission to get the best results. Patients must receivethe correct care in order to fully recover.

The data for the recommended care in this report is for theyear 2010. Higher scores are better.

R

How is the information forrecommended carecollected and validated?

The information is collected fromhospitals’ patient medical records.Each year, the Centers for Medicareand Medicaid Services (CMS)selects a sample of hospitals toreview for consistency of their data.Based on this audit, New Jerseyhospitals passed this review.

To learn more about the datacollection methods and the CMSaudit process, see the technicalreport at www.nj.gov/health/hpr.

What do the hospitalscores mean?

Recommended Care Measures showhow each hospital treats eligiblepatients with heart attack,

pneumonia, heart failure and

patients having surgery by lookingat the number of times a patientreceived the correct care. Thisinformation is converted into apercentage. The score for eachrecommended care measure reflectsthe percentage of eligible patientswho received the recommendedtreatment. For example, a score of85% means that the hospitalprovided the recommended care for85 out of 100 eligible patients.

The goal for each hospital is to

reach 100% so that all eligible

patients receive the best care.Patients who should not receive thetreatments due to their specificconditions (contraindications) are

excluded from the measures. Pleasenote that small differences inhospital scores are not significantand do not indicate real differencesin hospital quality. It is better to lookat larger differences.

Each of the four conditions has an

Overall Score. An Overall Score is asummary of all the scores for theindividual measures for eachcondition. The Overall Scores areshown on pages 10-11. Scores anddescriptions for individual measuresare provided on the pages 12-29.

All recommended care tables include

the Top 10% and Top 50% performers

for each measure. These scores helpdetermine which hospitals are amongthe top 10% or 50% of NJ hospitalsfor the specific measure. If yourhospital has a score that is equal to orgreater than the score displayed atthe top of the table, it is among thetop 10% or 50% performers in NJ onthat specific measure.

Are all heart attack,pneumonia, heart failureand surgery patients fromthe year 2010 included inthese figures?

No. Recommended care may notalways be the best treatment foreveryone. There may be specificreasons a patient should not receive acertain treatment. These are calledcontraindications. Patients who havecontraindications, or should notreceive the specific treatment, are notcounted in the measures.


A Consumer Report 9A Consumer Report

Why Focus on Recommended Care for Heart Attack, Pneumonia,Surgical Care Improvement and Heart Failure?

Heart Attack orAcute MyocardialInfarction (AMI)

See pages 12-15

Pneumonia

See pages 16-19

Surgical CareImprovement

See pages 20-25

Heart Failure

See pages 26-29

There are 785,000 new heart attacks and470,000 recurrent heart attacks annually,leading to 133,000 deaths.

With 1.2 million discharges from hospitals,pneumonia is the second most commonhealthcare-associated infection in hospitals,and is a major cause of death (approximately55,000 annually).

Surgical Care Infections occur at an estimated500,000 per year and account for approximately17% of all healthcare-associated infections peryear, the second most common type of medicalerror occurring in hospitalized patients.

Blood Clots occur in 25% of all major surgicalprocedures and result in over 50,000 deathsannually and are the most common preventablecause of hospital deaths.

Cardiac Complications occur in 2-5% ofpatients having non-cardiac surgery and 34% of patients having vascular surgery.

Around 5.8 million people in the U.S. haveheart failure; about 670,000 people arenewly diagnosed annually. About one in fivepeople die within one year from diagnosis.Heart failure contributed to approximately283,000 annual deaths.

Conditions National Importance Treatments Covered in This Report

• Aspirin at Arrival• Aspirin at Discharge• Beta Blocker at Discharge• ACE Inhibitor/ARB at Discharge• Smoking Cessation Advice• PCI Within 90 Minutes

• Pneumonia Vaccination • Influenza Vaccination • Antibiotic Timing• Antibiotic Selection• Blood Culture Before Initial Antibiotic• Smoking Cessation Advice

• Preventive Antibiotic Started • Preventive Antibiotic Stopped• Appropriate Antibiotic Received• Safe Hair Removal• Urinary Catheter Removal

• Treatment Preventing Blood Clots (VTE)Ordered

• Treatment Preventing Blood Clots (VTE)Received

• Beta Blocker Continued Before and AfterSurgery

• Controlled Blood Sugar for Heart Surgery Patients

• Left Ventricular Systolic (LVS) Assessment• ACE Inhibitor/ARB at Discharge• Discharge Instructions• Smoking Cessation Advice

Importance of These Measures


Overall ScoresHeart Attack, Pneumonia, Surgical Care Improvement and Heart Failure

Top 10% of hospitals scored equal to or higher than† 100 99 99 100


NORTHWEST

Sussex Newton Medical Center 99 97 94 99

St. Clare's Hospital-Sussex 100 ^ 99 92 97

Warren Hackettstown Regional Medical Center 100 97 96 99

Warren Hospital 100 99 99 99

NORTHEAST

Bergen Bergen Regional Medical Center 93 93 95 100

Englewood Hospital and Medical Center 100 97 98 98

Hackensack University Medical Center 99 96 95 96

Holy Name Hospital 100 98 99 100

Valley Hospital 98 99 96 92

Essex Clara Maass Medical Center 100 99 99 100

East Orange General Hospital 100 99 97 100

Mountainside Hospital 100 95 96 98

Newark Beth Israel Medical Center 100 99 99 100

Saint Barnabas Medical Center 100 98 98 100

St. Michael's Medical Center 96 96 98 97

UMDNJ-University Hospital 99 90 98 100

Hudson Bayonne Medical Center 99 97 97 97

Christ Hospital 96 94 93 98

Hoboken University Medical Center 99 93 92 100

Jersey City Medical Center 98 97 100 100

Meadowlands Hospital Medical Center 100 96 90 95

Palisades Medical Center of New York 99 99 98 100

Morris Chilton Memorial Hospital 98 96 96 96

Morristown Memorial Hospital 98 95 97 97

St. Clare's Hospital-Denville 99 99 97 96

St. Clare's Hospital-Dover 100 100 96 98

Passaic St. Joseph's Hospital and Medical Center 99 91 96 99

St. Joseph's Wayne Hospital 99 95 98 97

St. Mary's Hospital (Passaic) 98 97 94 97

Union Overlook Hospital 95 96 99 94

RWJ University Hospital at Rahway 100 96 98 95

Trinitas Hospital 94 91 96 95

CENTRAL

Hunterdon Hunterdon Medical Center 99 96 96 94

Mercer Capital Health System at Fuld 98 91 95 97

Capital Health System at Mercer 97 94 95 97

RWJ University Hospital at Hamilton 95 97 96 96

Region/County Hospital Name Heart Attack%

Heart Failure %

Pneumonia%


%

See footnotes at bottom of next page

11A Consumer Report

The scores summarize the percent of time that a hospitalprovided the correct care for heart attacks, pneumonia,heart failure and surgical patients in 2010. The Overall

Score is a composite of the individual measures for each ofthe specific conditions. Hospitals are alphabetical by regionand county. Higher scores are better. The goal is 100%.

Source: New Jersey Hospital Quality Data, 2010.

† These scores show which hospitals are among the top 10% or 50% of NJ hospitals for the specific measure. If your hospital has a score that is equal toor greater than the score displayed at the top, it is among the top 10% or 50% performers in NJ on the specific measure.

^Hospital score for this measure is based on a small number of patients (less than 25). Interpret data with caution.

Region/County Hospital Name Heart Attack%

Heart Failure %

Pneumonia%


%



CENTRAL (continued)

Mercer St. Francis Medical Center 99 95 96 97

University Medical Center at Princeton 99 99 99 100

Middlesex JFK Medical Center 97 96 94 93

Raritan Bay Medical Center-Old Bridge 97 99 98 100

Raritan Bay Medical Center-Perth Amboy 98 97 95 99

Robert Wood Johnson University Hospital 99 95 97 97

St. Peter's University Hospital 98 91 95 89

Monmouth Bayshore Community Hospital 100 99 99 100

CentraState Medical Center 99 98 91 95

Jersey Shore University Medical Center 99 97 98 98

Monmouth Medical Center 100 98 98 100

Riverview Medical Center 100 99 99 100

Ocean Community Medical Center 100 99 99 100

Kimball Medical Center 100 100 97 97

Ocean Medical Center 99 98 99 95

Southern Ocean Medical Center 100 95 96 97

Somerset Somerset Medical Center 98 96 98 99

SOUTH

Atlantic AtlantiCare Regional Medical Center-City 100 99 93 100

AtlantiCare Regional Medical Center-Mainland 99 98 96 100

Shore Memorial Hospital 100 99 99 98

Burlington Deborah Heart and Lung Center 100 93 97 99

Lourdes Medical Center of Burlington County 95 95 96 98

Virtua-Memorial Hospital Burlington County 96 96 98 93

Virtua-West Jersey Hospital Marlton 98 98 98 94

Camden Cooper Hospital/University Medical Center 99 97 98 100

Kennedy Mem. Hospitals UMC-Cherry Hill 99 98 99 98

Kennedy Mem. Hospitals UMC-Stratford 100 98 98 97

Our Lady of Lourdes Medical Center 100 99 98 100

Virtua-West Jersey Hospital Berlin 100 99 95 94

Virtua-West Jersey Hospital Voorhees 99 98 98 95

Cape May Cape Regional Medical Center 98 96 97 95

Cumberland South Jersey Healthcare Regional Medical Center 99 97 97 100

Gloucester Kennedy Mem. Hospitals UMC-Wash. Twp. 95 97 98 94

Underwood-Memorial Hospital 99 98 96 100

Salem Memorial Hospital of Salem County 98 96 97 99

South Jersey Hospital-Elmer 100 97 97 99


Basic Facts on Treating Heart Attacks

he scores on pages 14-15 show how well hospitals areproviding care for eligible heart attack patients. A heartattack, or acute myocardial infarction (AMI), can occur if

the arteries supplying blood to the heart become blocked, and theblood supply is slowed or stopped. The heart can’t get theoxygen and nutrients it needs. The affected heart tissue may die.

Symptoms of a heart attack can include chest pain (crushing,squeezing or burning pain in the center of the chest whichmay radiate to the arm or jaw), shortness of breath, pain inthe upper abdomen, dizziness, faintness, chills, sweating ornausea, and/or a feeling of impending doom. Skin may feelcold or clammy, and patients may appear gray and look ill.

Additional or different symptoms may occur for women.They can include heartburn, abdominal pain and/or unusualor unexplained fatigue. Sometimes there are no symptoms.

Patients at higher risk of experiencing complications to anyof the recommended treatments are excluded from thescores for that particular treatment. These patients are saidto have “contraindications” to the treatment.

The data for this report is for the year 2010.

Remember: Higher percentages indicate betterperformance. The goal is to achieve 100%.

TRecommended Care

Aspirin at Arrival

D This score tells you the percent of heart attack patients whoreceived aspirin within 24 hoursbefore or after hospital arrival.

D This information is importantbecause taking aspirin as soon assymptoms of a heart attack beginmay reduce the severity of theattack. Aspirin can help prevent ordissolve existing blood clots.Continued use of aspirin may helpreduce the risk of another heartattack.

Aspirin at Discharge

D This score tells you the percent ofheart attack patients prescribedaspirin at discharge from thehospital.

D This information is importantbecause aspirin can help preventor dissolve existing blood clots.Continued use of aspirin may helpreduce the risk of another heartattack.

Beta Blocker at Discharge

D This score tells you the percent ofheart attack patients prescribed abeta blocker at discharge from thehospital.

D This information is importantbecause beta blockers aremedicines that lower bloodpressure, treat chest pain (angina)and heart failure, and help preventheart attacks. Beta blockers relievethe stress on the heart by slowingthe heart rate and reducing theforce with which the heartcontracts to pump blood. Theyalso help keep blood vesselsthroughout the body fromconstricting.

13A Consumer Report

Section 2: Recommended Care/Process of Care Measures

ACE Inhibitor or ARB atDischarge

D This score tells you the percent ofheart attack patients with leftventricular systolic dysfunction(LVSD) who were prescribed anangiotensin-converting enzyme(ACE) inhibitor or an angiotensinreceptor blocker (ARB) atdischarge from the hospital.

D This information is importantbecause ACE inhibitors andARBs are medicines that can helpreduce the risk of death after aheart attack. Continued use mayhelp prevent heart failure. ACEinhibitors and ARBs modify theeffects of hormones (angiotensinII) that regulate blood pressureand influence the healing processof the heart. They are prescribedto lower blood pressure and thuslessen the workload of the heart.

Smoking Cessation Advice

D This score tells you the percent ofheart attack patients with a historyof smoking cigarettes who receivedadvice before discharge from thehospital on how to quit smoking.

D This information is importantbecause smoking is linked to heartattacks. Quitting may help preventanother one.

PCI Within 90 Minutes

D This score tells you the percent of heart attack patientswho underwent angioplasty, or a Percutaneous CoronaryIntervention (PCI), within 90minutes after arrival at a hospital.

D This information is importantbecause PCI is a procedure toopen the blocked blood vessels, re-establishing the blood supply tothe heart muscle. It involvesinserting a catheter (a flexibletube) often through the leg.Increasingly, cardiologists chooseto do a PCI instead of prescribingclot-dissolving medication.However, PCI is not available at every general hospital in New Jersey.

To find out if a New Jerseyhospital is licensed to performPCI, refer to the table on thefollowing pages. “NL” indicatesthat the hospital is not licensed toperform PCI. If a hospital has ascore in the “PCI Within 90Minutes” column, then thehospital is licensed to performPCI.


Heart Attack Treatment Scores

Hospital NameAspirin Arrival

%

AspirinDischarge

%

Beta Blocker

Discharge%

ACEI/ARBDischarge

%

SmokingCessation

Advice%

PCI within 90 Minutes

%

Recommended Care

Top 10% of hospitals scored equal to or higher than† 100 100 100 100 100 100 100


AtlantiCare Regional Medical Center-City 100 100 100 ^ 100 ^ 100 ^ 100 ^ NL

Bayshore Community Hospital 100 100 100 100 100 ^ 100 ^ NL

Clara Maass Medical Center 100 100 100 100 100 100 100

Community Medical Center 100 100 100 100 100 100 100

East Orange General Hospital 100 100 100 100 100 ^ 100 ^ NL

Hackettstown Regional Medical Center 100 100 100 100 100 ^ 100 ^ NL

Holy Name Hospital 100 100 100 100 100 100 100 ^

Kennedy Mem. Hospitals UMC-Stratford 100 100 100 100 100 ^ 100 ^ NL

Meadowlands Hospital Medical Center 100 100 100 ^ 100 ^ 100 ^ NA NL

Mountainside Hospital 100 100 100 100 100 ^ 100 ^ 100

Newark Beth Israel Medical Center 100 100 100 100 100 100 100 ^

RWJ University Hospital at Rahway 100 100 100 100 100 ^ 100 ^ NL

Shore Memorial Hospital 100 100 100 100 100 ^ 100 ^ NL

South Jersey Hospital-Elmer 100 100 100 ^ 100 ^ 100 ^ 100 ^ NL

Southern Ocean County Hospital 100 100 100 100 100 ^ 100 ^ NL

St. Clare's Hospital-Dover 100 100 100 ^ 100 ^ 100 ^ 100 ^ NL

St. Clare's Hospital-Sussex 100 ^ 100 ^ 100 ^ 100 ^ 100 ^ NA NL

Virtua-West Jersey Hospital Berlin 100 100 100 ^ 100 ^ 100 ^ 100 ^ NL

Warren Hospital 100 100 100 ^ 100 ^ 100 ^ 100 ^ NL

Deborah Heart and Lung Center 100 100 100 100 98 100 NA

Saint Barnabas Medical Center 100 100 100 100 100 100 97

Kimball Medical Center 100 100 98 100 100 ^ 100 ^ NL

Riverview Medical Center 100 100 100 100 100 ^ 100 96

Monmouth Medical Center 100 99 100 100 100 ^ 100 ^ 100 ^

Our Lady of Lourdes Medical Center 100 99 100 100 100 100 89 ^

Englewood Hospital and Medical Center 100 100 100 100 100 100 94

Underwood-Memorial Hospital 99 100 100 100 100 ^ 100 97

Cooper Hospital/University Medical Center 99 100 99 100 98 100 87 ^

Bayonne Medical Center 99 100 100 100 100 ^ 100 83 ^

University Medical Center at Princeton 99 99 100 100 100 ^ 100 ^ 96

Virtua-West Jersey Hospital Voorhees 99 98 100 100 100 ^ 100 ^ NL

Newton Medical Center 99 100 100 97 100 ^ 100 ^ NL

Hackensack University Medical Center 99 100 99 99 98 100 95

Robert Wood Johnson University Hospital 99 100 100 100 99 100 86

St. Joseph's Hospital and Medical Center 99 100 100 99 93 100 99

Ocean Medical Center 99 100 98 100 91 ^ 100 ^ 94

Jersey Shore University Medical Center 99 100 99 99 100 100 92

Palisades Medical Center of New York 99 98 100 100 100 ^ 100 ^ NL

OverallScore %


15A Consumer Report

Hospital NameAspirin Arrival

%

AspirinDischarge

%

Beta Blocker

Discharge%

ACEI/ARBDischarge

%

SmokingCessation

Advice%

PCI within 90 Minutes

%

The scores summarize the percent of time that a hospital gave patients the correct care for heart attacks in 2010. The Overall Score is a composite

of the six heart attack measures.

Higher scores are better. The goal is 100%.


NA (Not Applicable) indicates that the hospital reported no cases for this measure.NL (Not Licensed) indicates that the hospital is not licensed to perform PCI procedure.† These scores show which hospitals are among the top 10% or 50% of NJ hospitals for the specific measure. If your hospital has a score that is equal to

or greater than the score displayed at the top, it is among the top 10% or 50% performers in NJ on the specific measure.^ Hospital score for this measure is based on a small number of patients (less than 25). Interpret data with caution.



CentraState Medical Center 99 98 100 100 100 ^ 100 ^ NL

St. Joseph's Wayne Hospital 99 97 100 100 100 ^ 100 ^ NL

St. Clare's Hospital-Denville 99 100 99 100 100 ^ 100 ^ 91

Hoboken University Medical Center 99 98 100 ^ 100 ^ 96 100 NL

AtlantiCare Regional Medical Center-Mainland 99 100 100 99 100 ^ 100 ^ 89

South Jersey Healthcare Regional Medical Center 99 99 97 100 96 ^ 100 ^ NL

Hunterdon Medical Center 99 99 100 99 100 ^ 100 ^ 96

Kennedy Mem. Hospitals UMC-Cherry Hill 99 98 100 98 100 100 NL

UMDNJ-University Hospital 99 100 100 100 100 100 80

St. Francis Medical Center 99 99 99 100 91 100 69

Morristown Memorial Hospital 98 99 100 99 100 ^ 100 ^ 88

Chilton Memorial Hospital 98 99 99 100 100 ^ 100 ^ 89

Capital Health System at Fuld 98 97 100 ^ 100 ^ 100 ^ 100 NL

Virtua-West Jersey Hospital Marlton 98 100 99 99 100 100 84

Somerset Medical Center 98 99 99 99 80 ^ 100 ^ 87

Memorial Hospital of Salem County 98 100 100 ^ 100 ^ 100 100 NL

Raritan Bay Medical Center-Perth Amboy 98 99 97 98 96 100 90

Valley Hospital 98 99 98 98 100 ^ 100 89

St. Mary's Hospital (Passaic) 98 98 100 100 NA 100 ^ 75 ^

Cape Regional Medical Center 98 100 94 ^ 94 ^ 100 ^ 100 ^ NL

St. Peter's University Hospital 98 99 100 97 94 100 80 ^

Jersey City Medical Center 98 100 98 96 100 ^ 100 ^ 87

Capital Health System at Mercer 97 100 98 96 100 ^ 100 ^ 80 ^

Raritan Bay Medical Center-Old Bridge 97 98 90 100 87 100 ^ NL

JFK Medical Center 97 99 99 99 90 ^ 100 ^ 83

Christ Hospital 96 97 95 96 95 100 94

St. Michael's Medical Center 96 99 94 96 93 100 67 ^

Virtua-Memorial Hospital Burlington County 96 100 98 99 86 90 ^ 48

Overlook Hospital 95 99 96 97 100 ^ 100 ^ 82

Lourdes Medical Center of Burlington County 95 97 88 97 100 ^ 100 NL

RWJ University Hospital at Hamilton 95 94 97 100 100 ^ 100 ^ 77

Kennedy Mem. Hospitals UMC-Wash. Twp. 95 98 89 91 96 100 NL

Trinitas Hospital 94 97 95 95 100 ^ 100 ^ 76

Bergen Regional Medical Center 93 100 ^ 92 ^ 83 ^ 100 ^ 100 ^ NL

OverallScore %


Basic Facts on Treating Pneumonia

he scores on pages 18-19 show how well hospitals aretreating eligible pneumonia patients. Pneumonia is aninflammation of the lungs caused by an infection. Many

different organisms can cause pneumonia, including bacteria,viruses and fungi.

Pneumonia can range from very mild to very severe, even fatal,depending on the type of organism causing it as well as the ageand current health of the individual. Symptoms can include fever,fatigue, difficulty breathing, chills, “wet” cough and chest pain.

Patients at higher risk of experiencing complications to anyof the recommended treatments are excluded from thescores for that particular treatment. These patients are saidto have “contraindications” to the treatment.

The data in this report is for the year 2010.


TRecommended Care

Antibiotic Timing

D This score tells you the percent ofpneumonia patients who receivedan antibiotic within 6 hours ofhospital arrival.

D This information is importantbecause early antibiotic treatmentcan cure bacterial pneumoniaquickly and reduce the possibilityof complications. However, thereis controversy about thedesirability of hospitals achieving a100% score on this measure.Pneumonia can be difficult todiagnose quickly, and there issome concern that this measureprovides hospitals aninappropriate incentive to useantibiotics for all potentialpneumonia patients before makinga firm diagnosis.

Overuse of antibiotics reducesquality of health care since it canresult in bacterial resistance tothese antibiotics.

Pneumonia Vaccination

D This score tells you the percent ofpneumonia patients 65 years ofage and older who were assessedfor and, if needed, given thepneumonia vaccine beforedischarge from the hospital.

D This information is importantbecause a pneumonia vaccinationmay help prevent future bacterialpneumonia and lower the risk ofcomplications.

Influenza Vaccination

D This score tells you the percent ofpneumonia patients 50 years ofage and older who were assessedfor and given, if needed, theinfluenza vaccine before dischargefrom the hospital during the fluseason.

D This information is importantbecause flu shots are highlyeffective in preventing influenza-related pneumonia, a serious andsometimes deadly lung infectionthat is highly contagious. Patients50 years old and older areparticularly vulnerable, andgetting the flu shot during fluseason helps protect them fromanother lung infection andprevent the spread of influenza.

17A Consumer Report


Antibiotic Selection

D This score tells you the percent ofpneumonia patients who receivedthe most appropriate initialantibiotic.

D This information is importantbecause different antibiotics treatspecific bacterial infections. Theinitial antibiotic selection should bethe best treatment choice for thattype of pneumonia.

Blood Culture Before Initial Antibiotic

D This score tells you the percent ofpneumonia patients in the hospitalwho had their blood taken andcultured in the EmergencyDepartment before receiving theirfirst antibiotic.

D This information is importantbecause a blood culture indicateswhich antibiotic will work best totreat that particular type ofbacterial pneumonia.


D This score tells you the percent ofpneumonia patients with a historyof smoking cigarettes who receivedadvice before discharge from thehospital on how to quit smoking.

D This information is importantbecause smoking may increase theseverity of your pneumonia andmake it more difficult to recover.Quitting may help improve yourcondition.


Pneumonia Treatment ScoresRecommended Care

Hospital NamePneumoniaVaccination

%

InfluenzaVaccination§

%

AntibioticTiming

%

AntibioticSelection

%

BloodCultures

%

SmokingCessation

Advice%



Kimball Medical Center 100 100 99 100 100 100 100

St. Clare's Hospital-Dover 100 100 98 100 100 100 100

St. Clare's Hospital-Denville 99 100 100 99 98 99 100

Clara Maass Medical Center 99 100 100 100 96 99 100

Our Lady of Lourdes Medical Center 99 98 99 100 100 99 100

Palisades Medical Center of New York 99 100 99 100 99 98 100 ^

St. Clare's Hospital-Sussex 99 100 100 100 97 98 100 ^

Newark Beth Israel Medical Center 99 100 100 98 98 98 100

Riverview Medical Center 99 100 99 98 98 99 100

Community Medical Center 99 100 100 99 94 100 100

Virtua-West Jersey Hospital Berlin 99 99 96 99 98 100 100

Raritan Bay Medical Center-Old Bridge 99 99 99 98 98 100 100

Bayshore Community Hospital 99 99 99 99 95 100 100

Warren Hospital 99 100 98 98 97 99 100

AtlantiCare Regional Medical Center-City 99 100 100 97 96 100 100

Shore Memorial Hospital 99 100 99 99 96 99 100

University Medical Center at Princeton 99 98 99 98 99 99 100 ^

Valley Hospital 99 99 99 98 97 99 100 ^

East Orange General Hospital 99 98 99 100 92 99 100

Monmouth Medical Center 98 98 98 99 98 99 100

Kennedy Mem. Hospitals UMC-Stratford 98 98 98 99 96 99 100

Underwood-Memorial Hospital 98 99 98 97 98 99 100

AtlantiCare Regional Medical Center-Mainland 98 100 100 97 96 99 100

Virtua-West Jersey Hospital Voorhees 98 99 97 99 95 99 100

Saint Barnabas Medical Center 98 97 97 99 97 100 100

Kennedy Mem. Hospitals UMC-Cherry Hill 98 99 100 97 95 98 100

Virtua-West Jersey Hospital Marlton 98 99 99 97 94 100 100

Holy Name Hospital 98 100 100 96 94 99 100

Ocean Medical Center 98 98 96 98 97 98 100

CentraState Medical Center 98 98 97 99 95 97 96

St. Mary's Hospital (Passaic) 97 97 98 98 95 97 100

Englewood Hospital and Medical Center 97 97 96 98 99 98 100 ^

South Jersey Hospital-Elmer 97 96 98 94 100 98 100 ^

South Jersey Healthcare Regional Medical Center 97 100 100 92 99 98 100

Newton Medical Center 97 97 95 99 95 97 100

Jersey Shore University Medical Center 97 96 94 99 94 100 100

Jersey City Medical Center 97 99 97 100 94 92 100

RWJ University Hospital at Hamilton 97 97 95 97 94 99 100

OverallScore %


19A Consumer Report

The scores summarize the percent of time that ahospital gave patients the correct care for pneumonia in2010.

The Overall Score is a composite of the six pneumoniascores.

Higher scores are better. The goal is 100%..


NA (Not Applicable) indicates that the hospital reported no cases for this measure.† These scores show which hospitals are among the top 10% or 50% of NJ hospitals for the specific measure. If your hospital has a score that is equal to

or greater than the score displayed at the top, it is among the top 10% or 50% performers in NJ on the specific measure.^ Hospital score for this measure is based on a small number of patients (less than 25).§ Influenza Vaccination includes information for January, February, October, November, and December 2010 discharges only.

Hospital NamePneumoniaVaccination

%

InfluenzaVaccination§

%

AntibioticTiming

%

AntibioticSelection

%

BloodCultures

%

SmokingCessation

Advice%

OverallScore %



Hackettstown Regional Medical Center 97 98 93 99 95 98 100 ^

Bayonne Medical Center 97 98 99 99 93 96 100

Kennedy Mem. Hospitals UMC-Wash. Twp. 97 96 96 97 98 97 99

Cooper Hospital/University Medical Center 97 89 96 99 98 96 100

Raritan Bay Medical Center-Perth Amboy 97 99 90 98 95 96 100

Overlook Hospital 96 98 100 97 91 96 91

St. Michael's Medical Center 96 93 92 96 97 100 100

Meadowlands Hospital Medical Center 96 94 92 100 95 97 100 ^

Virtua-Memorial Hospital Burlington County 96 95 95 99 95 96 100

Cape Regional Medical Center 96 95 93 98 96 94 100

Chilton Memorial Hospital 96 98 96 96 87 97 100

Memorial Hospital of Salem County 96 94 91 99 91 98 100

Hackensack University Medical Center 96 92 94 98 99 99 99

Hunterdon Medical Center 96 94 94 97 96 97 94

RWJ University Hospital at Rahway 96 97 94 95 94 97 94

Somerset Medical Center 96 94 90 98 95 98 100

JFK Medical Center 96 96 94 93 94 98 100

Mountainside Hospital 95 92 92 95 100 99 98

St. Francis Medical Center 95 93 90 92 97 99 100

St. Joseph's Wayne Hospital 95 95 92 95 94 98 100

Southern Ocean County Hospital 95 95 95 96 93 94 100

Robert Wood Johnson University Hospital 95 97 92 96 92 94 100

Morristown Memorial Hospital 95 96 94 90 97 97 100

Lourdes Medical Center of Burlington County 95 84 86 100 97 99 100

Capital Health System at Mercer 94 90 88 98 93 95 100

Christ Hospital 94 90 89 98 92 98 100

Deborah Heart and Lung Center 93 90 91 ^ 100 ^ NA NA 100 ^

Bergen Regional Medical Center 93 94 89 94 92 94 91 ^

Hoboken University Medical Center 93 91 90 93 89 97 100 ^

St. Joseph's Hospital and Medical Center 91 88 81 97 87 96 100

Trinitas Hospital 91 98 96 88 74 96 100

St. Peter's University Hospital 91 96 95 87 84 90 100

Capital Health System at Fuld 91 82 83 93 91 96 100

UMDNJ-University Hospital 90 92 96 91 91 82 98


Basic Facts on Surgical Care Improvement

he scores on pages 22-25 show how well hospitals areproviding their surgery patients with care to preventinfections and blood clots. Hospitals can reduce the risk

of wound infection after surgery by administering the propermedicines at the correct time on the same day of surgery. Signsof possible infection after surgery can include: a surgical woundthat is red, hot and swollen; a fever of over 100 degrees followinghospital discharge; a smelly or yellow/green fluid oozing out ofthe wound; or increased pain while taking pain medication.

The measures listed below represent the best practices for theprevention of infections and blood clots after selected surgeries

(e.g., colon surgery, hip and knee arthroplasty, abdominal andvaginal hysterectomy, cardiac surgery and vascular surgery).The data is for 2010.

Patients at higher risk of experiencing complications to any ofthe recommended treatments are excluded from the scores forthat particular treatment. These patients are said to have“contraindications” to the treatment.


TRecommended Care

Preventive AntibioticStarted 1 Hour BeforeSurgery

D This score tells you the percent ofeligible patients who receivedprophylactic or preventiveantibiotics within one hour priorto surgical incision.

D This information is importantbecause surgery patients givenantibiotics, medicines that preventand treat infections, within the hourbefore their operation are less likelyto get wound infections. Getting anantibiotic over an hour earlier orafter surgery begins is not aseffective.

Preventive AntibioticStopped Within 24 Hours

D This score tells you the percent ofeligible surgical patients whoseprophylactic or preventive antibioticswere stopped within 24 hours aftersurgery ended (or 48 hours afterCoronary Artery Bypass Graft orother cardiac surgery). Antibioticsare medicines that prevent and treatinfections.

D This information is importantbecause taking antibiotics for morethan 24 hours after routine surgery isusually not necessary and canincrease the risk of side effects, suchas stomach aches, serious types ofdiarrhea, and resistance to theantibiotic (the use of too muchantibiotic can prevent them frombeing effective).

There are, however, exceptions. If thesurgical site has been contaminated,there may be a need for additional

antibiotics after 24 hours. Talk toyour doctor to determine how longyou should take antibiotics aftersurgery.

Appropriate AntibioticReceived

D This score tells you the percent ofsurgery patients who received theappropriate preventiveantibiotic(s) for their surgery inorder to prevent a surgical woundinfection.

D This information is importantbecause certain antibiotics arerecommended to help preventwound infection for particulartypes of surgery. Hospitals canreduce the risk of wound infectionafter surgery by making sure thepatient gets the right medicationat the right time on the day oftheir surgery.

Safe Hair RemovalD This score tells you the percent of

surgery patients who had hairremoved from the surgical areabefore surgery, using a safermethod than a razor, such aselectric clippers or hair removalcream.

21A Consumer Report


D This information is importantbecause medical research hasshown that shaving with a razorcan increase the risk of infection.It is therefore safer to use electricclippers or hair removal cream.

Urinary Catheter RemovalD This score tells you the percent

of surgery patients who had aurinary catheter removed on thefirst or second day after surgery.

D This information is importantbecause medical research hasshown that the longer a catheteris in place, the greater the risk ofthe patient getting a urinary tractinfection (UTI). This measureexcludes patients who had aurological, gynecological orperineal procedure.

Treatment Preventing BloodClots (VTEs) Ordered

D This score tells you the percentof patients with certain types ofsurgeries whose doctors ordered

treatments to prevent blood clots,called venous thromboembolism(VTE) prophylaxis, anytime fromhospital arrival to 48 hours aftersurgery has ended.

D This information is importantbecause venous thrombosis is acondition in which a blood clot(thrombus) forms in the vein,limiting blood flow, causingswelling, redness and pain. If theclot breaks off (embolus), it canlodge itself in the lungs, causing apulmonary embolism, which canlead to death.

Doctors can order preventivetreatments called prophylaxis to

reduce the risk. These treatmentsmay include blood thinningmedications, elastic support stockings,or mechanical air stockings thatpromote blood circulation.

Treatment Preventing BloodClots (VTEs) Received

D This score tells you the percent ofpatients who received the appropriatetreatment to prevent blood clots calledvenous thromboembolism (VTE) atthe right time.

D This information is importantbecause venous thrombosis is acondition in which blood clots(thrombus) form in the vein, usuallyin the leg, thigh or pelvis, and maylimit blood flow, causing swelling,redness and pain. If the clot breaksoff, it can lodge itself in the lungs,causing a pulmonary embolism,which can lead to death.

Doctors can order preventivetreatments to reduce the risk. Thesetreatments may include bloodthinning medications, elastic supportstockings, or mechanical airstockings that promote bloodcirculation.

Controlled Blood Sugar for Heart Surgery PatientsD This score tells you the percent of all

heart surgery patients whose bloodsugar (blood glucose) is kept undergood control in the days right aftersurgery.

D This information is importantbecause all heart surgery patients gettheir blood sugar checked aftersurgery. Any patient who has highblood sugar after heart surgery has agreater chance of getting an infection.

Beta Blocker ContinuedBefore and After Surgery

D This score tells you the percent ofsurgery patients who were takingheart drugs called beta blockersbefore coming to the hospital andwere kept on the beta blockersduring the period just before andafter their surgery.

D This information is importantbecause when heart patients whotake beta blockers suddenly stoptaking them, they can experienceheart problems. Although it isstandard procedure to stop patients’medications before and after theirsurgery, staying on beta blockersbefore and after surgery makes itless likely problems will occur.

Beta blockers are medicines thatlower blood pressure, treat chestpain (angina) and heart failure,and help prevent heart attacks.


Surgical Care Improvement (SCIP) ScoresRecommended Care

Hospital NamePreventiveAntibioticStarted

%

PreventiveAntibioticStopped

%

AppropriateAntibioticReceived

%

Safe Hair

Removal%

UrinaryCatheterRemoval

%

Top 10% of hospitals scored equal to or higher than† 99 100 99 99 100 98


Jersey City Medical Center 100 100 100 100 100 100

Clara Maass Medical Center 99 100 98 99 100 99

Kennedy Mem. Hospitals UMC-Cherry Hill 99 100 99 100 100 99

Newark Beth Israel Medical Center 99 100 100 99 100 99

Bayshore Community Hospital 99 100 97 98 100 99

Community Medical Center 99 99 98 99 100 89

Overlook Hospital 99 99 98 98 100 97

Holy Name Hospital 99 99 99 98 100 99

Shore Memorial Hospital 99 100 98 98 100 94

Riverview Medical Center 99 100 98 99 100 97

University Medical Center at Princeton 99 98 99 97 100 97

Ocean Medical Center 99 100 96 99 100 96

Warren Hospital 99 100 97 99 100 96

Jersey Shore University Medical Center 98 100 98 99 100 97

Raritan Bay Medical Center-Old Bridge 98 100 98 99 100 97

St. Michael's Medical Center 98 100 99 99 100 95

Virtua-West Jersey Hospital Marlton 98 99 97 100 100 95

Englewood Hospital and Medical Center 98 99 98 99 100 97

Monmouth Medical Center 98 100 97 97 100 96

Virtua-Memorial Hospital Burlington County 98 97 98 99 100 96

Virtua-West Jersey Hospital Voorhees 98 99 97 99 100 88

Palisades Medical Center of New York 98 100 95 100 100 86

RWJ University Hospital at Rahway 98 100 99 99 100 87

Kennedy Mem. Hospitals UMC-Stratford 98 98 98 99 100 93

Kennedy Mem. Hospitals UMC-Wash. Twp. 98 99 98 99 99 88

Cooper Hospital/University Medical Center 98 97 98 97 100 96

Somerset Medical Center 98 99 99 99 100 83

Our Lady of Lourdes Medical Center 98 100 95 98 100 93

UMDNJ-University Hospital 98 99 97 97 100 97

St. Joseph's Wayne Hospital 98 99 98 98 100 97

Saint Barnabas Medical Center 98 100 97 98 100 92

East Orange General Hospital 97 98 93 98 100 87

Kimball Medical Center 97 100 93 99 100 88

St. Clare's Hospital-Denville 97 99 97 98 100 88

Bayonne Medical Center 97 100 95 100 100 87

South Jersey Hospital-Elmer 97 98 98 99 100 90

Morristown Memorial Hospital 97 96 97 97 100 95

Memorial Hospital of Salem County 97 96 99 98 100 86

OverallScore %


23A Consumer Report

The scores summarize the percent of time that ahospital gave patients the correct care for preventing infection in surgical patients in 2010. The Overall Score is a composite of the eight

surgical care improvement scores, excluding VTEProphylaxis Ordered.

Higher Scores Are Better. The goal is 100%.



NA (Not Applicable) indicates that the hospital reported no cases for this measure.^ Hospital score for this measure is based on a small number of patients (less than 25). Interpret data with caution.

Hospital NamePreventiveAntibioticStarted

%

PreventiveAntibioticStopped

%

AppropriateAntibioticReceived

%

Safe Hair

Removal%

UrinaryCatheterRemoval

%



Cape Regional Medical Center 97 99 98 97 100 92

South Jersey Healthcare Regional Medical Center 97 98 95 97 100 96

Deborah Heart and Lung Center 97 98 93 100 100 98

Robert Wood Johnson University Hospital 97 97 96 98 100 91

Hackettstown Regional Medical Center 96 98 92 95 100 97

Hunterdon Medical Center 96 99 98 99 100 85

Trinitas Hospital 96 100 98 97 99 87

Southern Ocean County Hospital 96 99 94 99 100 94

St. Joseph's Hospital and Medical Center 96 97 96 97 100 94

Underwood-Memorial Hospital 96 96 93 97 100 88

Chilton Memorial Hospital 96 98 95 96 100 89

AtlantiCare Regional Medical Center-Mainland 96 97 93 97 100 93

Valley Hospital 96 99 96 97 100 95

Lourdes Medical Center of Burlington County 96 99 96 97 100 81

Mountainside Hospital 96 98 90 95 100 95

RWJ University Hospital at Hamilton 96 99 95 96 100 89

St. Francis Medical Center 96 96 89 98 100 98

St. Clare's Hospital-Dover 96 100 95 100 100 88

Capital Health System at Fuld 95 99 91 95 100 84

Hackensack University Medical Center 95 100 96 97 100 91

Raritan Bay Medical Center-Perth Amboy 95 99 96 94 100 94

Capital Health System at Mercer 95 99 96 95 100 82

St. Peter's University Hospital 95 98 95 99 91 93

Virtua-West Jersey Hospital Berlin 95 100 ^ 94 ^ 94 ^ 100 64 ^

Bergen Regional Medical Center 95 100 100 96 100 91 ^

JFK Medical Center 94 98 94 96 99 74

St. Mary's Hospital (Passaic) 94 98 88 96 100 93

Newton Medical Center 94 96 90 90 100 90

AtlantiCare Regional Medical Center-City 93 97 94 93 100 74

Christ Hospital 93 96 90 95 100 94

St. Clare's Hospital-Sussex 92 100 ^ 100 ^ 75 ^ 100 ^ 88 ^

Hoboken University Medical Center 92 100 94 96 100 80

CentraState Medical Center 91 96 92 95 99 90

Meadowlands Hospital Medical Center 90 98 92 91 100 100 ^

OverallScore %

continued on next page


Surgical Care Improvement (SCIP) ScoresRecommended Care

Hospital NameVTE

ProphylaxisOrdered

%

VTEProphylaxisReceived

%

ControlledBlood Sugar

%

Beta Blocker

Continued%

Top 10% of hospitals scored equal to or higher than†: 99 100 99 98 100

Top 50% of hospitals scored equal to or higher than†: 97 98 96 97 96

Jersey City Medical Center 100 100 99 98 100

Clara Maass Medical Center 99 100 100 NA 100

Kennedy Mem. Hospitals UMC-Cherry Hill 99 100 100 NA 94

Newark Beth Israel Medical Center 99 98 98 97 100

Bayshore Community Hospital 99 100 98 NA 98

Community Medical Center 99 100 100 NA 100

Overlook Hospital 99 100 98 NA 99

Holy Name Hospital 99 99 98 NA 98

Shore Memorial Hospital 99 99 98 NA 98

Riverview Medical Center 99 98 97 NA 98

University Medical Center at Princeton 99 99 98 NA 100

Ocean Medical Center 99 98 98 NA 99

Warren Hospital 99 99 98 NA 99

Jersey Shore University Medical Center 98 99 98 97 97

Raritan Bay Medical Center-Old Bridge 98 98 99 NA 93

St. Michael's Medical Center 98 96 92 98 100

Virtua-West Jersey Hospital Marlton 98 99 98 NA 99

Englewood Hospital and Medical Center 98 96 95 98 100

Monmouth Medical Center 98 99 98 NA 98

Virtua-Memorial Hospital Burlington County 98 99 98 NA 97

Virtua-West Jersey Hospital Voorhees 98 98 97 NA 99

Palisades Medical Center of New York 98 100 100 NA 98

RWJ University Hospital at Rahway 98 97 95 NA 96

Kennedy Mem. Hospitals UMC-Stratford 98 100 99 NA 95

Kennedy Mem. Hospitals UMC-Wash. Twp. 98 98 98 NA 93

Cooper Hospital/University Medical Center 98 100 99 94 98

Somerset Medical Center 98 99 97 NA 93

Our Lady of Lourdes Medical Center 98 100 99 97 96

UMDNJ-University Hospital 98 97 95 93 100

St. Joseph's Wayne Hospital 98 97 94 NA 94

Saint Barnabas Medical Center 98 94 91 98 100

East Orange General Hospital 97 100 100 NA 92

Kimball Medical Center 97 97 94 NA 98

St. Clare's Hospital-Denville 97 98 97 NA 95

Bayonne Medical Center 97 98 96 NA 92

South Jersey Hospital-Elmer 97 96 96 NA 96

Morristown Memorial Hospital 97 99 99 90 92

Memorial Hospital of Salem County 97 99 99 NA 81

OverallScore %


25A Consumer Report

The scores summarize the percent of time that ahospital gave patients the correct care for preventinginfection in surgical patients in 2010. The OverallScore is a composite of the eight surgical care

improvement scores, excluding VTE ProphylaxisOrdered.




NA (Not Applicable) indicates that the hospital reported no cases for this measure.^ Hospital score for this measure is based on a small number of patients (less than 25). Interpret data with caution.

Hospital Name

Top 10% of hospitals scored equal to or higher than† 99 100 99 98 100


Cape Regional Medical Center 97 94 92 NA 94

South Jersey Healthcare Regional Medical Center 97 94 94 NA 95

Deborah Heart and Lung Center 97 79 79 91 99

Robert Wood Johnson University Hospital 97 98 98 88 99

Hackettstown Regional Medical Center 96 94 95 NA 100

Hunterdon Medical Center 96 96 94 NA 89

Trinitas Hospital 96 93 93 NA 98

Southern Ocean County Hospital 96 96 92 NA 92

St. Joseph's Hospital and Medical Center 96 93 89 92 99

Underwood-Memorial Hospital 96 99 97 NA 86

Chilton Memorial Hospital 96 95 93 NA 95

AtlantiCare Regional Medical Center-Mainland 96 95 92 98 91

Valley Hospital 96 92 85 97 89

Lourdes Medical Center of Burlington County 96 99 96 NA 91

Mountainside Hospital 96 96 88 NA 99

RWJ University Hospital at Hamilton 96 94 92 NA 95

St. Francis Medical Center 96 98 98 77 98

St. Clare's Hospital-Dover 96 92 91 NA 100

Capital Health System at Fuld 95 97 97 NA 95

Hackensack University Medical Center 95 84 83 95 92

Raritan Bay Medical Center-Perth Amboy 95 89 89 NA 91

Capital Health System at Mercer 95 92 91 NA 96

St. Peter's University Hospital 95 97 96 NA 91

Virtua-West Jersey Hospital Berlin 95 94 94 NA 100 ^

Bergen Regional Medical Center 95 88 88 NA 75 ^

JFK Medical Center 94 90 89 NA 88

St. Mary's Hospital (Passaic) 94 89 87 86 93

Newton Medical Center 94 92 92 NA 93

AtlantiCare Regional Medical Center-City 93 98 94 100 ^ 68

Christ Hospital 93 84 83 NA 92

St. Clare's Hospital-Sussex 92 100 ^ 90 ^ NA 50 ^

Hoboken University Medical Center 92 87 79 NA 81

CentraState Medical Center 91 81 81 NA 76

Meadowlands Hospital Medical Center 90 64 68 NA 100 ^

OverallScore %

VTEProphylaxis

Ordered %

VTEProphylaxisReceived

%

ControlledBlood Sugar

%

Beta Blocker

Continued%


Basic Facts on Treating Heart Failure

hese scores show how well hospitals are providingcare for eligible heart failure patients. Heart failure isa weakening of your heart’s muscle that reduces its

pumping power. Your body doesn’t get the oxygen andnutrients it needs. Your heart tries to pump more blood, butover time, the heart muscle walls weaken.

Symptoms of heart failure can include shortness of breath fromfluid in the lungs, dizziness, fatigue, weakness, cold and clammyskin, or rapid and irregular heartbeat. Heart failure can resultfrom coronary artery disease, heart attack, cardiomyopathy(heart muscle damage from infection, alcohol or drugs), or an

overworked heart (caused by high blood pressure, kidneydisease, diabetes, or a defect from birth).

Patients at higher risk of experiencing complications to any ofthe recommended treatments are excluded from the scoresfor that particular treatment. These patients are said to have“contraindications” to the treatment.

The data in this report is for the year 2010.


T

Left Ventricular Systolic(LVS) Function Assessment

D This score tells you the percent ofheart failure patients who hadtheir LVS function evaluatedbefore hospital arrival, duringhospitalization, or had a testplanned following discharge.

D This information is importantbecause an assessment of yourheart’s left side, the mainpumping chamber, is needed todetermine how well your heart ispumping. Results help determineappropriate treatment.

ACE Inhibitor or ARB atDischarge

D This score tells you the percent ofheart failure patients with leftventricular systolic dysfunction(LVSD) prescribed anangiotensin converting enzyme(ACE) inhibitor or anangiotensin receptor blocker(ARB) at discharge from thehospital.

D This information is importantbecause ACE inhibitors and ARBsare medicines that modify theeffects of hormones that regulateblood pressure and influence thehealing process of the heart. Sincethese two drugs work differently,your doctor will decide which drugis most appropriate for you.

Discharge Instructions

D This score tells you the percent ofpatients who received writteninstructions or educational materialat hospital discharge addressing:activity level, diet, dischargemedications, follow-upappointment, weight monitoring,and instructions if symptomsworsen.

D This information is importantbecause heart failure is a chroniccondition which must be managedclosely to prevent repeathospitalizations and furtherdamage to the heart and otherorgans.

Recommended Care

27A Consumer Report


D This score tells you the percent ofheart failure patients with ahistory of smoking cigarettes whoreceived advice on how to quitsmoking before hospitaldischarge.

D This information is importantbecause smoking increases yourrisk for developing blood clotsand further heart disease, whichcan lead to heart attacks, heartfailure or stroke. Smoking causesblood vessels to thicken making itharder for blood to flow to theheart.


Heart Failure Treatment ScoresRecommended Care

Hospital NameLVS

Assessment %

ACEI/ARBDischarge

%

DischargeInstructions

%


%



AtlantiCare Regional Medical Center-City 100 100 100 100 100

AtlantiCare Regional Medical Center-Mainland 100 100 100 100 100

Bayshore Community Hospital 100 100 100 100 100

Bergen Regional Medical Center 100 100^ 100^ 100^ 100^

Clara Maass Medical Center 100 100 100 100 100

Hoboken University Medical Center 100 100 100 100 100^

Holy Name Hospital 100 100 100 100 100

Newark Beth Israel Medical Center 100 100 100 100 100

South Jersey Healthcare Regional Medical Center 100 100 100 100 100

Underwood-Memorial Hospital 100 100 100 100 100

University Medical Center at Princeton 100 100 100 100 100^

UMDNJ-University Hospital 100 100 100 100 100

Jersey City Medical Center 100 100 100 100 100

Riverview Medical Center 100 100 100 100 100

East Orange General Hospital 100 100 99 100 100

Community Medical Center 100 100 100 99 100

Monmouth Medical Center 100 100 100 99 100

Raritan Bay Medical Center-Old Bridge 100 100 98 100 100^

Our Lady of Lourdes Medical Center 100 100 100 99 100

Cooper Hospital/University Medical Center 100 100 99 100 100

Palisades Medical Center of New York 100 99 100 100 100^

Saint Barnabas Medical Center 100 100 100 99 100^

Raritan Bay Medical Center-Perth Amboy 99 100 98 99 100

Newton Medical Center 99 100 98 99 100

Memorial Hospital of Salem County 99 99 100 99 100

South Jersey Hospital-Elmer 99 100 93 100 100^

Deborah Heart and Lung Center 99 100 94 100 100

St. Joseph's Hospital and Medical Center 99 98 98 100 100

Warren Hospital 99 100 100 96 100^

Somerset Medical Center 99 98 100 100 100

Hackettstown Regional Medical Center 99 100 100 96 100^

Shore Memorial Hospital 98 100 98 97 100

Mountainside Hospital 98 100 99 96 100^

St. Clare's Hospital-Dover 98 100 96 97 100^

Christ Hospital 98 99 92 100 100

Kennedy Mem. Hospitals UMC-Cherry Hill 98 100 92^ 96 100

Englewood Hospital and Medical Center 98 99 99 95 100

Jersey Shore University Medical Center 98 100 98 94 100

OverallScore

%


29A Consumer Report

The scores summarize the percent of time that a hospital gave patients the correct care for heart failure in 2010. The Overall Score is a

composite of the four heart failure scores.




^ Hospital score for this measure is based on a small number of patients (less than 25).

Heart Failure Treatment Scores

Hospital NameLVS

Assessment %

ACEI/ARBDischarge

%

DischargeInstructions

%


%



Lourdes Medical Center of Burlington County 98 98 93 98 100

Capital Health System at Mercer 97 98 99 96 100

Kennedy Mem. Hospitals UMC-Stratford 97 98 96 96 100

Robert Wood Johnson University Hospital 97 100 99 93 100

Morristown Memorial Hospital 97 100 89 98 100

St. Francis Medical Center 97 100 98 93 100

St. Joseph's Wayne Hospital 97 100 95 93 100^

Southern Ocean County Hospital 97 100 97 92 100

Capital Health System at Fuld 97 98 95 96 100

St. Clare's Hospital-Sussex 97 100 100^ 92 100^

Bayonne Medical Center 97 94 98 100 100^

Kimball Medical Center 97 100 99 90 100

St. Mary's Hospital (Passaic) 97 100 100 90 100

St. Michael's Medical Center 97 100 97 91 100

RWJ University Hospital at Hamilton 96 100 95 92 100

Hackensack University Medical Center 96 100 97 91 100

St. Clare's Hospital-Denville 96 100 97 90 100

Chilton Memorial Hospital 96 100 93 91 100

Virtua-West Jersey Hospital Voorhees 95 100 99 87 100

CentraState Medical Center 95 100 99 88 96

Ocean Medical Center 95 99 98 89 100

RWJ University Hospital at Rahway 95 100 99 82 100

Trinitas Hospital 95 98 86 93 100

Cape Regional Medical Center 95 100 93 88 100

Meadowlands Hospital Medical Center 95 91 94 99 100^

Kennedy Mem. Hospitals UMC-Wash. Twp. 94 100 91 87 100

Overlook Hospital 94 97 88 93 97

Virtua-West Jersey Hospital Marlton 94 99 97 84 100

Hunterdon Medical Center 94 99 98 85 100^

Virtua-West Jersey Hospital Berlin 94 100 100 82 100

JFK Medical Center 93 100 94 82 100

Virtua-Memorial Hospital Burlington County 93 99 95 83 100

Valley Hospital 92 99 92 80 100^

St. Peter's University Hospital 89 99 97 71 100

OverallScore

%


Heart Attack Aspirin at Arrival 99 99

Aspirin at Discharge 99 99

Beta Blocker at Discharge 99 99

ACEI / ARB at Discharge 98 97

Smoking Cessation Advice 100 100

PCI within 90 Minutes 89 91

Pneumonia Pneumococcal Vaccination 96 95

Influenza Vaccination 95 94

Antibiotic Timing - 6 Hours 97 96

Antibiotic Selection 95 93

Blood Cultures 97 96


Heart Failure LVS Assessment 99 99

ACEI / ARB at Discharge 97 95

Discharge Instructions 94 91


Surgical Care Preventive Antibiotic Started 98 97

Improvement Preventive Antibiotic Stopped 96 96

Appropriate Antibiotic Received 98 98

Safe Hair Removal 100 100

Urinary Catheter Removal 93 91

VTE Prophylaxis Ordered 96 95

VTE Prophylaxis Received 95 94

Controlled Blood Sugar for Heart Surgery Patients 93 94

Beta Blocker Continued 96 94

Quality Measure NationalNew Jersey

Statewide Scores Compared to National Scores

he table below compares statewide scores to nationalscores for Recommended Care Measures. New Jerseyscores for the 25 recommended care measures are the

same as in the tables on the previous pages, which are based ondata collected from hospital medical records for 2010. The

National Scores are from the Centers for Medicare andMedicaid Services (CMS) for the same year and from the samedatabase.

Remember: Higher scores are better and the goalis 100%.

TRecommended Care

Condition

For 2010, New Jersey performedbetter than the national average onmost recommended care qualitymeasures. Of the 25 recommendedcare measures, New Jersey hospitalperformance exceeded national

scores on 15 measures and was equalto national norms on eight measures.New Jersey fell below national scoresfor two measures, Controlled BloodSugar for Heart Surgery Patients andPCI Within 90 Minutes.

Most statewide scores have reachedclose to the 100% goal. This meansbetter care for all NJ patients.

Section 3:

Patient Safety Indicators(PSIs)

D Understanding and Using PatientSafety Indicators (PSIs)

D Basic Facts on Patient SafetyIndicators

D Patient Safety Indicator Rates

D Statewide PSI Rates Compared to

National Rates

Pati

ent

Safe

tyIn

dic

ato

rs (

PSIs

)


Understanding Using Patient Safety Indicators (PSIs)

ven in the best hospitals, some patients will experiencecomplications either after an operation or as a result ofother care. This section of the report shows how well

each hospital is providing safe patient care by examining thenumber of medical errors or “adverse events” that occur duringsurgeries, medical procedures, and child birth. These measuresof occurrence of adverse events or serious medical errors amonghospitalized patients are called Patient Safety Indicators (PSIs).

In 2009, the New Jersey legislature enacted the Patient SafetyAct (P.L. 2009, C. 122) requiring that the Department includehospital-specific data on patient-safety performance andserious medical errors in the annual New Jersey HospitalPerformance Report. Evidence shows that most of the adverseevents classified under each PSI are potentially preventable.This section of the report focuses on the 12 PSIs mandated forpublic reporting.

PSIs differ from the way the recommended care measures arecalculated. Unlike the recommended care measures, a lowerrate in PSIs indicates better performance by a hospital. WithPSIs, lower rates mean fewer medical errors or adverseevents. In addition, the numbers on the PSI tables on pages 36-39 are not scores or simple percentages, as used with therecommended care measures; they are either rates or actualvolume of medical errors.

PSIs were developed at the national level by the Agency forHealthcare Research and Quality (AHRQ) after years ofresearch and analysis. AHRQ developed the PSIs to helphospitals identify potentially preventable adverse events orserious medical errors. When an adverse event is identified,hospitals can put corrective systems in place to prevent theerror from recurring. The Centers for Medicare and MedicaidServices (CMS) lists some of these errors as “never events.”

E

How is the data collected? The data comes from the New Jerseyhospital discharge database alsoknown as the Uniform Bill (UB) data.Hospitals submit these data to thestate. The data used for this analysisare from 2010.

What do the rates mean? The PSIs tables on pages 36-39 showthe occurrence of medical errors oradverse events in each of the 72licensed hospitals in New Jersey. EachPSI measure shows the extent to whichpatients experience a particularproblem during their hospital stay. Arate is expressed as the number ofcomplications or medical errors per1,000 eligible hospital discharges.

For example, suppose a hospital had1,000 obstetric patients who hadvaginal deliveries without the assistanceof an instrument. Suppose 43 out ofthese 1,000 patients experiencedtrauma during delivery. Then, the rateof occurrence of trauma at this hospitalfor that type of patient (obstetricpatient who had a vaginal delivery

without an instrument) would be 43per every 1,000 patients or 4.3% (4.3out of 100).

For PSIs, lower numbers meanfewer medical errors/adverseevents. This is different from therecommended care measures,where higher numbers mean betterperformance.

How are the rates calculated?Hospitals that treat sicker or olderpatients may be unfairly comparedto other hospitals with healthierpatients. It is very important tomake adjustments for suchdifferences, so that hospitals may becompared fairly. The PSIs rates inthis report were calculated byapplying the AHRQ PSIs Software(Version 4.2) to the 2010 hospitaldischarge (UB) data. The software isknown for its strength in performing“risk-adjustment”.

Risk-adjustment is a statisticalmethod that takes into accountdifferent patient characteristics (e.g.age, sex, comorbidities, severity of

illness, etc.) while calculating a rate.For example, if a patient has a pre-existing chronic illness before enteringthe hospital, this condition mayincrease the likelihood or risk of thatpatient acquiring a complication andperhaps not surviving the procedureor treatment. Advanced age isanother example of a characteristicthat may increase the risk ofexperiencing complications.

Since 2008, hospitals have beenreporting data on Present onAdmission (POA) for each patient ontheir UB forms. Patients may haveother illnesses and conditions(comorbidities) upon admission inaddition to the health problem forwhich they were admitted. It is oftendifficult to separate these pre-existingconditions from new health problemsacquired during hospitalization. ThePOA indicator identifies these pre-existing conditions and those that occurduring the hospital stay. This way,patients with the POA can be excludedfrom the rate calculation, whenappropriate, so that performancecomparison remains fair and balanced.

&

33A Consumer Report

Section 3: Patient Safety Indicators (PSIs)

A technical report containingadditional details such as the totalnumber of adverse event, the totalnumber of eligible discharges,observed and expected adverse eventrates and the 95% confidenceintervals for the risk-adjusted rates(when applicable) is available at:www.nj.gov/health/hpr.

How do I read the table?

The footnote labels, "better thanstatewide average” and “worse thanstatewide average,” shown at thebottom of the tables on pages 36-39describe the interpretation of thePSI rates in a meaningful way. Theselabels help identify hospitals thathave better than average, average, orworse than average performancescompared to the statewide perform-ance, which is shown on the top rowof the table and labeled “StatewideRate.” Confidence Intervals are usedto identify those hospitals that have‘worse than average’ or ‘better thanaverage’ complication rates whencompared to statewide average.

When a hospital’s rate is marked bya single asterisk, it means the hospi-tal’s performance is better than thestatewide average, meaning feweradverse events than the statewiderate.

When a hospital’s rate is marked bydouble asterisks, it means the hospi-tal’s performance is worse than thestatewide average, meaning moreadverse events than the statewiderate.

When a hospital’s rate is not markedby an asterisk, it means the hospital’sperformance is the same as or similarto the statewide rate.

Hospital rates are determined afteradjusting for the risk factors of theirpatients. A hospital’s rate is ‘worsethan average’ if its 95% confidenceinterval falls completely above thestatewide rate. By comparison, a hos-pital’s rate is ‘better than average’ ifits 95% confidence interval falls com-pletely below the statewide rate.

Some rates that appear large are notmarked as ‘worse than average’ whileothers that appear small are notmarked as ‘better than average.’ Thereason for such cases may be thatrates calculated from small numbersof events tend to have wider confi-dence intervals that make thestatewide rate fall within the interval,giving the appearance of good per-formance by that hospital comparedto a hospital whose rates are based onlarge numbers of events.

Information on confidence intervals isnot shown in the tables on pages 36-39 but is included in the calculationsand can be found in the technicalreport at www.nj.gov/health/hpr.

Can I use PSIs to drawconclusions about patientsafety in NJ hospitals?

Performance on a single PSI measurecannot reliably indicate actual qualitydifferences among hospitals.Examining the results of all the 12 PSIs

together will produce a more completepicture of overall quality of care.

Even then, PSIs are not intended asdefinitive quality measures and cannotprovide a complete picture of qualityperformance in a hospital. However,evidence has shown that these patientsafety measures do show differences inhospital performance. Specifically,they measure differences in the hospi-tals’ ability to reduce severe andpotentially preventable complicationsand adverse events.

Remember: Lower rates arebetter and mean the hospital hasfewer adverse events than thestatewide average rate.


Basic Facts About Patient Safety Indicators (PSIs)his section presents brief descriptions of each of the 12PSIs covered in this report and why it is important toreport them publicly. Most of these adverse events are

considered potentially preventable (i.e., with good care,hospitals can prevent most of these adverse events).

Lower rates are better and mean fewer medicalerrors.

TForeign Body Left in DuringProcedure: D This indicator is measured using

volume of occurrence – not a rate.It tells you the number of patientswho had a foreign objectaccidentally left in their bodyduring surgical or medicalprocedures. It is considered anever-event and happens veryrarely. All cases with pre-existingconditions are excluded from themeasure.

D This information is importantbecause foreign objects such assponges, medical instruments,bandages, should never beaccidentally left in a patient’sbody after an operation orprocedure. This error ispreventable, and hospitals withsuch incidents need to putsystems in place to preventrecurrence.

Iatrogenic Pneumothorax: D This rate tells you the number of

patients who had air leaking outof their lungs due to an accidentalpuncture during a medical orsurgical procedure per 1,000discharges. The medical term forthis accident is iatrogenic(unfavorable response after amedical/surgical treatment)pneumothorax (a collapsed lung).

D This information is importantbecause this medical error, whichsometimes requires a tube in thepatient’s chest to remove theextra air, is potentially avoidable.

Postoperative Hip Fracture: D This rate tells you the number of

patients who broke a hip bone froma fall during a hospital stay followingany kind of operation or procedureper 1,000 surgical discharges(operating room procedures).

D This information is importantbecause a patient who experiencesa fall after an operation and breakshis/her hip bone is a type ofmedical error that is usuallypreventable. A fall can happen fordifferent reasons, such as beinggiven too much pain medication,having too little supervision whentrying to walk after an operation orit may just happen. This is a veryrare event.

Postoperative Hemorrhageor Hematoma: D This rate tells you the number of

patients with postoperative

hemorrhage (too much bleeding)or postoperative hematoma (largeblood clot) or drainage ofhematoma per 1,000 surgicaldischarges following a surgicalprocedure.

D This information is importantbecause a hematoma is a largeblood clot that can cause toomuch bleeding. Some of thesecomplications may requireanother operation to stop thebleeding or remove the bloodclots. This medical error ispotentially avoidable.

Postoperative PulmonaryEmbolism (PE) or Deep VeinThrombosis (DVT): D This rate tells you the number of

patients with PE, a blood clot inthe lungs, or DVT, a blood clot ina large vein, per 1,000 dischargesof surgery patients from theoperating room. The numberexcludes obstetric patients.

D This information is importantbecause a PE, which is a blood clotin the lungs, or DVT, which is ablood clot in a large vein, canoccur during a surgical procedure.If the DVT breaks away andtravels through the bloodstream, itcould block a blood vessel in thepatient’s lungs, causing PE.

Postoperative Sepsis: D This rate tells you the number of

hospitalized patients that get aserious bloodstream infection(nosocomial postoperative sepsis)after surgery per 1,000 electivesurgery patients. A seriousinfection of the bloodstreamcaused by toxin-producingbacteria, known as sepsis, canoccur after surgery. The rateexcludes patients with pre-existinginfections as well as those withcompromised immunity systemsuch as cancer. Obstetric patientsare also excluded.

D This information is important becauseit tells you the level of care providedby the hospital to prevent sepsis(infections) in patients. Analysis ofthese particular infections mayprovide a screen for potentialmedical errors and a method for

Section 3: Patient Safety Indicators (PSIs)

monitoring trends in infectionsover time.

Hospitals following the appropriateprotocols, such as requiring stafffrequently wash their hands, shouldsee improvement of post-operativesepsis or other infections over time.

Postoperative WoundDehiscence: D This rate tells you the number of

patients who had re-closure ofsurgical wound(s) (wound

dehiscence) in the abdominal wallor pelvic area per 1,000 cases ofabdominopelvic surgeries. Woundre-closure is performed after thewound from surgical operation isaccidently split open (wounddehiscence). Abdominopelvic

surgical procedures include thoseperformed on the stomach, liver,spleen, gallbladder, pancreas,kidneys, most of the small andlarge intestines, urinary bladderand internal reproductive organs.The rate excludes patients withpre-existing conditions (POA)and all obstetric admissions.

D This information is importantbecause it shows you how often asurgical wound in the stomach orpelvic area is split open after anoperation. Some or all of thesecomplications may requiretreatment with another majoroperation to fix the wound. Wounddehiscence following surgery is amedical error that can be avoided.

Accidental Puncture orLaceration: D This rate tells you the number of

patients who had an accidental cut

or lacerations during a medicalprocedure per 1,000 discharges. Thenumber excludes patient with pre-existing conditions as well asobstetric admissions.

D This information is importantbecause such a cut or lacerationcan cause a hole or tear in anorgan of the body while receivingmedical treatment. This medicalerror can usually be avoided.

Transfusion Reaction: D This indicator is measured using

volume of occurrence – not a rate. Ittells you the number of patients whohad a bad reaction to a blood

transfusion. It is considered a never-event and happens very rarely. Allcases with pre-existing conditionsare excluded from the measure.

D This information is importantbecause it measures majorreactions to blood transfusions.Using the wrong type of blood orblood substitute are examples ofwhy this type of medical error mayoccur.

Birth Trauma - Injury toNeonate: D This rate tells you the number of

birth trauma (injury to neonate)

cases per 1000 live births caused bymedical complications during laborand delivery. The rate excludessome pre-term infants and infantswith osteogenic imperfecta.

D This information is importantbecause some birth traumas are

potentially preventable errors.

Examples of what may cause abirth trauma to a neonate include:

bleeding; delay ordering amedically necessary cesareansection (c-section); misuse offorceps or a vacuum extractorduring delivery; or failure torespond to an umbilical cord thatis dangerously wrapped aroundthe newborn.

Obstetric Trauma - VaginalDelivery with Instrument: D This rate tells you the number of

obstetric trauma cases (3rd or 4thdegree lacerations, other obstetriclacerations) during instrument-

assisted vaginal deliveries per1,000 discharges.

D This information is importantbecause trauma cases duringvaginal delivery that require theuse of forceps or other instrumentassistance is a medical error thatis potentially preventable.

Obstetric Trauma - VaginalDelivery without Instrument: D This rate tells you the number of

obstetric trauma cases (4thdegree lacerations, other obstetriclacerations) per 1,000 vaginaldeliveries that occurred without a

medical instrument.

D This information is importantbecause it tells you the number of

potentially preventable injuries orlacerations that occurred during avaginal delivery that did notrequire instrument assistance.

Please refer to the Technical Reportat www.nj.gov/health/hpr for a moredetailed description and statisticalanalysis of the PSIs.

A Consumer Report 35


Patient Safety Indicator (PSI) Rates 2010 per 1,000 hospital discharges

Hospital NameForeign body left in during

procedure

Iatrogenic pneumothorax

Post-operativehip fracture

Post-operativehemorrhage or hematoma

Post-operative pulmonary embolism

(PE) or deep veinthrombosis (DVT)

Post-operativesepsis

National average (2008) 184 0.5 0.1 3.4 9.4 12.7

Statewide number of adverse events (2010) 27 292 6 435 1,461 256

Statewide average rate (2010) N/A 0.3 0.0 3.7 6.6 14.5

Atlanticare Regional Medical Center-City 0 0.3 0.0 0.9 4.7 24.5

Atlanticare Regional Medical Center-Mainland 0 0.0 0.0 2.1 5.5 20.5

Bayonne Medical Center 0 0.5 0.0 4.4 7.5 71.6^**

Bayshore Community Hospital 0 0.4 1.7 ** 1.5 2.3 27.6

Bergen Regional Medical Center 0 0.0 0.0 0.0 15.0 64.0

Cape Regional Medical Center 0 0.4 0.0 4.0 1.5 * 26.1

Capital Health Regional Medical Center 0 0.1 0.0 2.3 11.9 ** 14.9

Capital Health System at Mercer 1 0.0 2.2 ** 3.3 4.5 24.6

CentraState Medical Center 1 0.6 0.0 4.1 4.8 21.3

Chilton Memorial Hospital 0 0.9 ** 0.0 6.4 3.6 0.0

Christ Hospital 0 0.4 0.0 3.9 2.8 50.7**

Clara Maass Medical Center 0 0.3 0.0 2.3 2.4 * 39.7**

Community Medical Center 0 0.2 0.0 4.1 4.0 10.1

Cooper Hospital/University Medical Center 2 1.3 ** 0.0 3.5 10.7 ** 12.5

Deborah Heart and Lung Center 2 0.2 0.0 6.9 ** 2.4 * 0.0^

East Orange General Hospital 0 0.2 0.0 2.5 5.9 0.0^

Englewood Hospital and Medical Center 0 0.3 0.0 3.5 5.3 19.7

Hackensack University Medical Center 1 0.3 0.0 4.5 12.6 ** 17.3

Hackettstown Community Hospital 0 0.4 0.0 3.6 9.7 58.0**

Hoboken University Medical Center 0 0.0 0.0 3.6 4.8 20.3

Holy Name Hospital 0 0.4 0.0 3.5 7.2 46.0**

Hunterdon Medical Center 1 0.8 0.0 0.0 4.0 14.8

Jersey City Medical Center 0 0.2 0.0 2.3 0.5 * 0.0

Jersey Shore University Medical Center 1 0.3 0.2 3.7 2.4 * 8.5

JFK Community Medical Center-Edison 0 0.2 0.0 1.4 * 12.3 ** 16.6

Kennedy Memorial Hospitals UMC-Cherry Hill 0 0.4 0.0 0.0 4.3 54.0^

Kennedy Memorial Hospitals UMC-Stratford 0 0.0 0.0 3.0 3.8 0.0

Kennedy Memorial Hospitals UMC-Wash. Twp. 0 0.6 0.0 1.6 2.4 0.0

Kimball Medical Center 0 0.0 0.0 0.0 4.8 0.0^

Lourdes Medical Center of Burlington Cty. 0 0.5 0.0 14.9 ** 4.0 10.3

Meadowlands Hospital Medical Center 0 0.7 0.0 2.9 0.0_

Memorial Hospital of Salem County 0 1.0 0.0 7.9 6.6 22.4

Monmouth Medical Center 1 0.1 0.0 4.1 8.0 5.4

Morristown Memmorial Hospital 2 0.3 0.0 3.9 7.6 4.4*

Mountainside Hospital 0 0.5 0.0 1.6 5.1 20.1

Newark Beth Israel Medical Center 1 0.6 0.0 4.7 4.0 * 17.9

Newton Memorial Hospital 0 0.4 0.0 1.7 3.5 24.4

Ocean Medical Center 0 0.2 0.0 3.2 3.2 * 21.2

Our Lady of Lourdes Medical Center 0 0.8 ** 0.0 4.9 3.6 * 5.5*


37A Consumer Report

Source: New Jersey rates are from the 2010 UB Data, while the national rates come from the AHRQ Comparative Data Report derived from the 2008 Nationwide Inpatient Sample (NIS) database.

^ Rate is based on less than 30 cases/patients. Interpret data with caution.

* Better than state average.

** Worse than state average.

N/A Not Applicable (Foreign body left in during procedure' is reported in volume instead of rate, because it is a rare event).

- Hospital reported less than 3 cases/patients for this measure, which is too small to report.

Hospital NameForeign body left in during

procedure

Iatrogenic pneumothorax

Post-operativehip fracture

Post-operativehemorrhage or hematoma

Post-operative pulmonary embolism

(PE) or deep veinthrombosis (DVT)

Post-operativesepsis

National average (2008) 184 0.5 0.1 3.4 9.4 12.7

Statewide number of adverse events (2010) 27 292 6 435 1,461 256

Statewide average rate (2010) N/A 0.3 0.0 3.7 6.6 14.5

Overlook Hospital 0 0.3 0.4 6.3 ** 10.1 ** 8.3

Palisades Medical Center - NY PHS 0 0.8 0.0 0.0 5.0 0.0

Raritan Bay Medical Center-Old Bridge 0 0.0 0.0 0.0 6.5 38.4

Raritan Bay Medical Center-Perth Amboy 0 0.4 0.0 0.0 6.1 28.2 ^

Riverview Medical Center 0 0.2 0.0 4.7 2.2 * 13.1

RWJ University Hospital 7 0.7 ** 0.0 5.3 ** 7.7 16.7

RWJ University Hospital at Hamilton 0 0.2 0.0 6.8 ** 2.8 * 5.4

RWJ University Hospital at Rahway 0 0.2 0.0 1.7 5.2 0.0

Shore Memorial Hospital 0 0.1 0.0 6.5 5.3 9.5

Somerset Medical Center 0 0.2 0.0 5.1 10.4 ** 0.0 *

South Jersey Healthcare Regional MC 0 0.5 0.0 4.3 4.4 17.3

South Jersey Hospital-Elmer 0 0.0 0.0 0.0 5.7 0.0

Southern Ocean County Hospital 0 0.7 0.0 2.6 4.1 18.0

Saint Barnabas Medical Center 2 0.4 0.0 4.0 9.2 ** 18.0

St. Clare's Hospital-Denville 0 0.1 0.0 1.7 8.6 0.0

St. Clare's Hospital-Dover 0 0.0 0.0 0.0 11.5 43.0 ^

St. Clare's Hospital-Sussex 0 0.0 0.0 0.0 9.8_

St. Francis Medical Center-Trenton 0 0.6 0.0 9.1 ** 5.8 18.4

St. Joseph's Hospital and Medical Center 1 0.3 0.0 1.5 * 3.5 * 26.4 **

St. Joseph's Wayne Hospital 0 0.0 0.0 0.0 3.7 44.2

St. Mary's Hospital (Passaic) 0 0.2 0.6 4.1 2.4 34.3 **

St. Michael's Medical Center 0 0.3 0.0 2.2 3.1 * 15.9

St. Peter's University Hospital 0 0.1 0.0 0.5 * 14.0 ** 16.9

Trinitas Hospital 0 0.4 0.0 0.7 * 1.7 * 31.6

UMDNJ-University Hospital 1 0.4 0.0 2.7 8.1 33.3 **

Underwood-Memorial Hospital 1 0.4 0.0 4.4 5.8 0.0

University Medical Center at Princeton 0 0.3 0.0 3.0 3.8 4.2

Valley Hospital 1 0.4 0.0 3.5 11.6 ** 12.2

Virtua-Memorial Hospital Burlington Cty. 0 0.2 0.0 3.4 7.2 10.6

Virtua-West Jersey Hospital Berlin 0 0.2 0.0 8.0 4.0 0.0 ^

Virtua-West Jersey Hospital Marlton 0 0.1 0.0 5.0 7.1 3.4

Virtua-West Jersey Hospital Voorhees 1 0.1 0.0 3.0 3.1 5.7

Warren Hospital 0 0.4 0.0 6.4 8.7 15.7

The rate is the number of avoidable medical errors for every1,000 eligible discharges from the hospital in 2010. Two of the12 PSI procedures, Foreign Object Left in During Procedure

and Transfusion Reaction, are not presented as rates but asvolume or number of events. Lower rates are better andmean fewer medical errors for that procedure or condition.

continued on next page


Patient Safety Indicator (PSI) Rates 2010 per 1,000 hospital discharges

Hospital NamePost-operative

wound dehiscence

Accidentalpuncture orlaceration

Transfusionreaction

Birth Trauma -Injury to

Neonate+

Obstetric trauma -vaginal delivery

with instrument+

Obstetric trauma -vaginal delivery

without instrument+

National average (2008) 2.1 3.0 27 2.3 146.4 23.8

Statewide number of adverse events (2010) 64 1,337 3 257 534 1,317

Statewide average rate (2010) 2.0 1.7 N/A 2.6 133.6 22.6

Atlanticare Regional Medical Center-City 0.0 0.9 0 0.0 ^_

0.0^

Atlanticare Regional Medical Center-Mainland 0.0 1.0 0 4.0 57.1 9.4

Bayonne Medical Center 4.2 0.7 0_ _ _

Bayshore Community Hospital 0.0 1.0 0_ _

0.0^

Bergen Regional Medical Center 32.0 ** 0.0 0_ _ _

Cape Regional Medical Center 0.0 1.1 0 1.8 92.6 10.0

Capital Health Regional Medical Center 4.6 0.5 0_ _ _

Capital Health System at Mercer 3.7 1.9 0 1.4 211.5 15.3

CentraState Medical Center 1.4 3.3** 0 1.2 250.0 ^ 24.1

Chilton Memorial Hospital 0.0 3.4** 0 1.1 250.0 47.6

Christ Hospital 6.2 1.3 0 1.6 0.0 ^ 3.2

Clara Maass Medical Center 1.3 1.1 0 0.6 69.8 11.5

Community Medical Center 2.7 1.7 0 1.9 133.3 27.9

Cooper Hospital/University Medical Center 5.4 ** 1.9 0 4.6 84.7 26.1

Deborah Heart and Lung Center 0.0 ^ 1.8 0_ _ _

East Orange General Hospital 7.7 0.5 0_ _ _

Englewood Hospital and Medical Center 1.8 0.9 0 2.1 124.0 22.0

Hackensack University Medical Center 2.0 2.0 0 5.1 95.2 16.3

Hackettstown Community Hospital 5.3 1.9 0 1.4 87.0 ^ 21.8

Hoboken University Medical Center 0.0 0.5 0 0.7 160.0 ^ 39.9

Holy Name Hospital 0.0 0.7 0 1.5 121.2 14.5

Hunterdon Medical Center 0.0 0.7 0 1.9 225.0 27.6

Jersey City Medical Center 0.0 1.4 0 0.6 134.6 20.5

Jersey Shore University Medical Center 1.2 3.6** 0 1.2 54.1 14.9

JFK Community Medical Center-Edison 2.6 1.0 0 1.1 100.0 25.5

Kennedy Memorial Hospitals UMC-Cherry Hill 9.3 0.7 0_ _ _

Kennedy Memorial Hospitals UMC-Stratford 0.0 3.2 0_ _ _

Kennedy Memorial Hospitals UMC-Wash. Twp. 5.2 1.8 0 3.2 117.6 19.7

Kimball Medical Center 3.0 0.6 0 5.5 160.5 13.5

Lourdes Medical Center of Burlington Cty. 0.0 2.9 0 5.2 83.3 ^ 10.2

Meadowlands Hospital Medical Center 0.0 3.2 0 0.0 0.0 ^ 3.3

Memorial Hospital of Salem County 0.0 1.6 0 4.6 0.0 ^ 8.5

Monmouth Medical Center 0.0 1.3 1@ 2.1 136.9 21.6

Morristown Memmorial Hospital 1.6 1.6 0 1.8 116.5 15.2

Mountainside Hospital 5.6 1.8 0 6.1 210.5 ^ 18.8

Newark Beth Israel Medical Center 2.4 1.7 0 1.6 266.7 24.0

Newton Memorial Hospital 3.3 2.1 0 2.2 76.9 ^ 20.5

Ocean Medical Center 1.5 1.4 0 0.0 115.4 44.2

Our Lady of Lourdes Medical Center 1.6 1.2 0 2.6 164.2 31.2


39A Consumer Report

Hospital NamePost-operative

wound dehiscence

Accidentalpuncture orlaceration

Transfusionreaction

Birth Trauma -Injury to

Neonate+

Obstetric trauma-vaginal delivery

with instrument+

Obstetric trauma-vaginal delivery

without instrument+

National average (2008) 2.1 3.0 27 2.3 146.4 23.8

Statewide number of adverse events (2010) 64 1,337 3 257 534 1,317

Statewide average rate (2010) 2.0 1.7 N/A 2.6 133.6 22.6

Overlook Hospital 0.0 1.8 0 2.1 125.9 14.1

Palisades Medical Center - NY PHS 0.0 1.3 0 1.3 250.0 ^ 41.2

Raritan Bay Medical Center-Old Bridge 0.0 0.9 0_ _ _

Raritan Bay Medical Center-Perth Amboy 5.6 1.6 0 2.6 333.3 ^ 30.5

Riverview Medical Center 3.2 1.5 0 2.9 137.9 29.8

RWJ University Hospital 2.1 3.5 ** 0 2.3 283.0 50.7

RWJ University Hospital at Hamilton 0.0 2.6 0 3.1 68.2 24.3

RWJ University Hospital at Rahway 3.7 0.2 0_ _ _

Shore Memorial Hospital 0.0 0.7 0 2.7 83.3 ^ 15.7

Somerset Medical Center 1.9 1.2 0 5.6 202.7 34.7

South Jersey Healthcare Regional MC 1.9 2.7 0 5.1 83.3 ^ 11.9

South Jersey Hospital-Elmer 0.0 2.1 0 0.0 0.0 ^ 27.5

Southern Ocean County Hospital 0.0 0.8 0 6.6 181.8 ^ 44.4

Saint Barnabas Medical Center 2.7 2.8 ** 0 2.5 138.1 23.1

St. Clare's Hospital-Denville 0.0 2.5 0 2.7 400.0 ^ 34.3

St. Clare's Hospital-Dover 0.0 5.2 ** 0_ _ _

St. Clare's Hospital-Sussex 0.0 ^ 0.0 0_ _ _

St. Francis Medical Center-Trenton 0.0 2.3 0_ _ _

St. Joseph's Hospital and Medical Center 3.8 0.7 * 1 1.5 160.0 ^ 23.2

St. Joseph's Wayne Hospital 0.0 0.2 0_ _ _

St. Mary's Hospital (Passaic) 0.0 1.3 0 0.0 142.9 ^ 10.2

St. Michael's Medical Center 3.7 1.0 0_ _ _

St. Peter's University Hospital 0.0 1.3 0 1.8 142.9 19.2

Trinitas Hospital 0.0 0.9 0 0.4 98.4 17.5

UMDNJ-University Hospital 3.2 1.0 0 5.8 87.0 11.9

Underwood-Memorial Hospital 2.7 0.9 0 2.1 0.0 ^ 24.4

University Medical Center at Princeton 0.0 1.6 0 2.1 158.7 19.8

Valley Hospital 2.5 1.4 0 4.5 114.1 44.0

Virtua-Memorial Hospital Burlington Cty. 0.0 2.0 1 4.0 59.7 31.0

Virtua-West Jersey Hospital Berlin 0.0 0.8 0_ _ _

Virtua-West Jersey Hospital Marlton 4.6 1.0 0_ _ _

Virtua-West Jersey Hospital Voorhees 1.4 1.8 0 3.2 169.0 21.5

Warren Hospital 3.5 2.4 0_ _ _

The rate is the number of avoidable medical errors for every1,000 eligible discharges from the hospital in 2010. Two of the12 PSI procedures, Foreign Object Left in During Procedure

and Transfusion Reaction, are not presented as rates but asvolume or number of events. Lower rates are better andmean fewer medical errors for that procedure or condition.

Source: New Jersey rates are from the 2010 UB Data, while the national rates come from the AHRQ Comparative Data Report derived from the 2008 Nationwide Inpatient Sample (NIS) database.

^ Rate is based on less than 30 cases/patients. Interpret data with caution.

* Better than state average.

** Worse than state average.

@ This number reflects incorrect coding made and attested to by Monmouth Medical Center.

N/A Not Applicable (Transfusion reaction' is reported in volume instead of rate, because it is a rare event).

- Hospital reported less than 3 cases/patients for this measure, which is too small to report.

+ Observed rate (not risk-adjusted).


National numbers are from AHRQ's Comparative data for the PSIs based on the 2008 Nationwide Inpatient Sample, computed using Version 4.1b of the

PSI Software.

New Jersey's numbers are derived from its 2010 UB data using Version 4.2 of the PSI SAS Software.

Ω Indicator is reported in volume, not rate.

@ One of the 3 cases is a result of incorrect coding made and attested by the facility that reported the case into the UB database.

New Jersey's Statewide PSI Rates Compared to National Rates

he table below shows New Jersey’s statewide estimates forthe 12 Patient Safety Indicators (PSIs) in this report. TheNew Jersey statewide estimates are based on the 2010 UB

data calculated using the Agency for Healthcare Research and Quality(AHRQ) PSIs Software (Version 4.2). The national estimates comefrom AHRQ’s national comparative data derived from the 2008

Compared to the 2008 nationalPSIs estimates (the latest availableat the time of this report), NewJersey performed better than thenational average for 7 of the 10PSIs that are measured using rates.

T Nationwide Inpatient Sample (NIS) using Version 4.1b of the PSIs software.

Remember: Lower rates are better and mean thehospital has fewer adverse events than thestatewide average.

The three measures where New Jerseyperformed worse than the nationalaverage were - post-operative hemor-rhage or hematoma, post-operativesepsis, and birth trauma - injury to

neonate. These differences may inpart be due to differences in yearsof data used or module versionapplied, as well as differences indata reporting by states.

Foreign Body Left in During Procedure Ω 184 27

Iatrogenic Pneumothorax 0.50 0.34

Post-operative Hip Fracture 0.10 0.05

Post-operative Hemorrhage or Hematoma 3.40 3.69

Post-operative Pulmonary Embolism or Deep Vein Thrombosis 9.40 6.56

Post-operative Sepsis 12.70 14.45

Post-operative Wound Dehiscence 2.10 1.96

Accidental Puncture or Laceration 3.00 1.72

Transfusion Reaction Ω 27 3@

Birth Trauma - Injury to Neonate 2.30 2.56

Obstetric Trauma - Vaginal Delivery with Instrument 146.40 133.60

Obstetric Trauma - Vaginal Delivery without Instrument 23.80 22.55

Patient Safety Indicators (PSIs) National New Jersey

Section 4

Healthcare-AssociatedInfections (HAIs)

D Understanding Measures for Healthcare-Associated Infections (HAIs)

D Central Line-Associated BloodstreamInfections (CLABSI) Data

D Catheter-Associated Urinary TractInfections (CAUTI) Data

D Overall Surgical Site Infections (SSI) Data

D Abdominal Hysterectomy Surgical SiteInfections Data

D Coronary Artery Bypass Graft (CABG)Surgical Site Infections Data

D Preventing Surgical Site Infections (SSI)

D Preventing Central Line-AssociatedBloodstream Infections (CLABSI)

D More About Catheter-Associated UrinaryTract Infections (CAUTI) and How to PreventThem

D Handwashing Helps Prevent Infections

Hea

lthc

are

Ass

ocia

ted

Infe

ctio

ns

(HA

Is)


Understanding Measures for Healthcare-Associated Infections

ealthcare-associated infections (HAIs) are amongthe top causes of unnecessary illnesses and deathsin the United States. HAIs are infections that patients

get while staying in a hospital or other healthcare facility –infections that the patients did not have before being admitted.They account for approximately 1.7 million infections andalmost 100,000 deaths annually1. HAIs result in extra days ofhospitalizations and higher health care costs. The estimatedfinancial impact of HAIs is between $28 billion to $33 billiona year2.

HAIs and patient safety are major public health issues thatrequire collaborations of government and the health careindustry. Reducing preventable HAIs is a priority for the Stateand for New Jersey hospitals. Signed in 2007, PublicReporting Legislation (P.L. 2007, C. 196) requires hospitals toreport HAI data to the State Department of Health and SeniorServices for public reporting in the Hospital PerformanceReport.

This section of the report shows how well New Jerseyhospitals are providing safe patient care by comparinghospital’s HAI experience with the national experience. It giveshospitals information to help reduce preventable HAIs andimprove patient safety.

The HAI measures are calculated differently than therecommended care and PSI measures. The HAIs are not reportedas scores or simple percentages; they are reported asStandardized Infection Ratios (SIR). More detailed explanationson SIR are provided below. Hospitals that performed better thanthe national experience have lower ratios.

Lower ratios are better because they suggest fewerinfections. The label “L” in the following tables identifies thebetter performing hospitals. The label “H” in the tablesidentifies the hospitals that performed below the nationalbaseline. Unlike recommended care measures and similarto PSIs, a lower ratio is better.

H

What HAIs are in thisyear’s report?This year’s report focuses on threetypes of HAIs; Surgical Site

Infections (SSIs) followingCoronary Artery Bypass Graft(CABG) and AbdominalHysterectomy procedures, Central

Line-Associated Bloodstream

Infections (CLABSIs), andCatheter-Associated Urinary Tract

Infections (CAUTIs).

Where do the data comefrom? New Jersey hospitals are requiredto report SSI, CLABSI, and CAUTI

events to the National HealthcareSafety Network (NHSN), ahealthcare-associated infectionsurveillance and prevention systemdeveloped by the federal Centersfor Disease Control and Prevention(CDC).

This report uses SSI data reported toNHSN by New Jersey hospitals in2009. Surgical procedures whichinvolve the placement of an implantmust be followed for a year. As aresult, surgery data will always bereported a year behind the other HAI

measures. CLABSI and CAUTI dataused in this report are from 2010.

Hospitals were provided theopportunity to verify the accuracy oftheir data. The first six months ofCLABSI data for 2010 were auditedwith funding from the CDC. Theremaining data in this report havenot been independently audited andvalidated.

What is Risk-Adjustment?

Some hospitals treat sicker or olderpatients than others. Sicker patientswho end up in the hospitals’ ICUs orCCUs are more likely to develophospital-acquired infections. Hospitalsaffiliated with a medical school

generally treat sicker patients thanmost hospitals. Not all hospitalshave the same types of ICUs. Forexample, patients in burn units ortrauma units are more at risk ofacquiring infections. Thesedifferences make it difficult tofairly compare hospitals’ HAIexperience.

The CDC has developed astatistical method called “risk-adjustment” that standardizes thedifferences across hospitals andallows all hospitals to be measuredmore fairly. This method ‘adjusts’for risk-factors that most oftenaffect the risks of developinginfections, such as type of ICUs,number of ICU beds, and hospitalsaffiliated with a medical school.This risk adjustment methodologywas used on the NJ data to “evenout the playing field.”

Section 4: Understanding Measures for Healthcare-Associated Infections

How are HAIs measuredand what do the measuresmean? The Standardized Infection Ratio

(SIR) is used to measure HAIs.The SIR is a summary measuredeveloped by CDC to track HAIs

at a national, state, local orhospital level over time. In basicterms, the hospital SIR is the totalnumber of “observed” or actualevents, also called infections,divided by the total number of“expected” events, which isderived from the national baselineexperience. More detailedexplanations of the “observed”and “expected” number of eventsas well as the SIR are providedbelow.

The hospital SIRs are comparedto the national experience, whichis a baseline SIR of 1.0. Theresults are summarized under thecolumn, National Comparison.This column classifies thehospitals’ performances by theletter “L” as “Lower thanExpected”, the letter S as “Similarto Expected”, or the letter “H” as“Higher than Expected”. Ahospital has performed better thanthe national baseline if theNational Comparison is markedwith the letter “L”. Thesehospitals appear better becausethey had fewer infections thanwhat is predicted based on thenational experience.

Hospitals labeled with the letter“H” had more infections thanwhat the national experiencepredicted. Those hospitals that

performed the same as the nationalexperience are labeled with a “S.”

According to CDC’s riskadjustment methodology, the SIR

for the national baseline is 1.0. Tointerpret a hospital’s SIR, comparethe SIR to 1.0, the national baselineSIR. This approach compares ahospital’s actual performance towhat would have occurred if thehospital performed the same as thenational baseline experience.

To learn more about the risk-adjustment method and how SIRs

are calculated, see the technicalreport at www.nj.gov/health/hpr.

What are Surgical SiteInfections?

A surgical site infection (SSI) is aninfection that occurs in the area ofthe body where the surgery tookplace. The SSI can be superficial,meaning it’s on the skin. It can alsobe serious and affect layers underthe skin, organs and/or implants.The infection must develop within30 days of the procedure. If theprocedure involves an implant ortransplant, monitoring for an SSI

must occur for a year following theprocedure.

According to the CDC, SSIs are thesecond most common HAI,accounting for 17 percent of all HAI

hospitalizations. Associated costs totreat an inpatient with a SSI arebetween $11,874 - $34,670 perinfection.2 One article notes thatmore than 750,000 SSIs occur eachyear in the United States which

results in an additional 2.5 millionhospital days which leads to morethan $1 billion in unnecessarycosts.6 (See pages 20-21, 57, 64-65for tips on preventing SSIs.

What Surgical SiteInfections are in thisreport?The SSIs which are included in this

report are from 2009. As noted pre-viously, surgical procedures whichinvolve an implant of any kind mustbe followed for a year. As a result,surgical site infection data will alwaysbe reported a year behind the otherHAI data.

This year’s report includes SSI datafrom Coronary Artery Bypass Graft

Continued on next page

A Consumer Report 43


(CABG) procedures and AbdominalHysterectomy (HYST) procedures.It is important to note that only 18of the 72 acute care hospitals arelicensed as Open Heart Surgery hos-pitals and are able to perform CABG

surgery. The surgical site infectiondata for 2009 were verified for accu-racy by each hospital but were notaudited.

What are the SSI results for New Jersey hospitalsfor 2009?

A total of 5,659 CABG procedureswere reported in NHSN by the 18Open Heart Surgery Hospitals inNew Jersey. The formula belowprovides the statewide observed,expected and SIR for CABGs:

Observed CABG infections=56Expected CABG infections=70.26

SIR=Observed / Expected = 56/70.26 = 0.80

The SIR of 0.80 indicates that theoverall observed CABG infectionswere 20% fewer than expected basedon the national data. The differenceis not statistically significant whichmeans the CABG infections in NewJersey were similar to the CABG

infections seen nationally.

A total of 8,324 AbdominalHysterectomy (HYST) procedureswere reported in NHSN by the hospi-tals in New Jersey who perform theprocedure. The formula below pro-vides the statewide observed, expect-ed and SIR for abdominal hysterec-tomies:

Observed HYST infections = 71Expected HYST infections = 58.87

SIR=Observed / Expected = 71/58.87 = 1.21

The SIR of 1.21 indicates that theoverall observed HYST infectionswere 21% more than expected basedon the national data. However, thedifference is not statistically signifi-cant which means the HYST infec-tions in New Jersey were similar tothe HYST infections seen nationally.

The overall SSI SIR takes intoaccount all surgeries that werereported in New Jersey in 2009:CABG and Abdominal Hysterectomy.The formula below provides thestatewide observed, expected and SIR

for the overall SSIs:

Observed SSIs = 127Expected SSIs = 129.13

SIR=Observed / Expected = 0.98

The SIR of 0.98 indicates that theoverall SSIs for New Jersey is 2%

fewer than expected based on thenational data. However, the differ-ence is not statistically significant.This means the surgical site infec-tions in New Jersey were similar tothe surgical site infections seennationally.

What are Central Line-Associated BloodstreamInfections (CLABSIs)?CLABSIs are primary bloodstreaminfections that are associated withthe presence of a central vascularcatheter. A central line is a tubethat is placed into a patient’s largevein, usually in the neck, chest, armor groin. The line is used to givefluids and medication, withdrawblood, and monitor the patient’scondition. A bloodstream infectioncan occur when microorganismssuch as bacteria and fungi enter,attach and multiply on the tubing orin fluid administered through thetubing and then enter the blood.

If you develop a central line-associated bloodstream infection,you may become ill with fevers andchills or the skin around the centralline may become sore and red.CLABSIs can be prevented throughproper management of the centralline. (See page 58 for tips on pre-venting CLABSI.)

It is estimated that CLABSIs cost$2.7 billion a year in the UnitedStates. According to the federalCDC, approximately 250,000CLABSIs occur annually with anestimated death rate of 12% to25% for each CLABSI3.

Continued from previous page

45A Consumer Report

What CLABSI data areincluded in this report?CLABSIs are monitored in manyinpatient locations within the hos-pital. This report includes CLABSI

events that occurred in adult, pedi-

atric critical/intensive care units

and neonatal intensive care units

(CCUs or ICUs and NICUs) ineach of the 72 acute carehospitalsin New Jersey during 2010. Mosthospital-acquired infections occurin intensive care units, which havethe sickest patients. It is importantto note that only the first half ofthe 2010 CLABSI data were audit-ed. The entire year of data wereverified for accuracy by each hospital.

What are the CLABSIresults for New Jersey for 2010? There were more than 269,000 cen-tral-line days reported to NHSN byNew Jersey acute care hospitals in2010. The formula below providesthe Statewide observed, expectedand SIR for CLABSIs:

Observed CLABSIs = 436Expected CLABSIs = 547.30


The SIR of 0.80 indicates thatCLABSIs for New Jersey was 20%fewer than expected based on thenational data. The difference isstatistically significant. This means

the central-line infections in New

Jersey were lower than the central-

line infections seen nationally.

What are Catheter-Associated Urinary TractInfections (CAUTIs)Catheter Associated Urinary Tract

Infections (CAUTI) are the mostcommonly reported healthcare-asso-ciated infection in acute care hospi-tals. A catheter is a drainage tubethat is inserted into the bladder. Thecatheter is left in place and is con-nected to a closed collection device.

More than 30 percent of infections inacute care hospitals are reported asCAUTIs.5 As with other HAIs,CAUTIs are also associated withincreased morbidity, mortality, lengthof stay and hospital costs. It is esti-mated that more than 449,000CAUTIs occur annually and patienthospital costs range from $862 to$1,007 per incident.2 CAUTIs arealso associated with more than13,000 deaths annually.5 (See page 59for more information including tipson preventing CAUTI.)

What CAUTI data areincluded in this report?

CAUTIs are monitored in many inpa-tient locations within the hospital.This report focuses on CAUTI events

that occurred in adult critical/inten-

sive care units (CCUs or ICUs) ineach of the 72 acute care hospitals inNew Jersey during 2010. This data isalso from the NHSN system notedabove. It is important to note thatthe CAUTI data in this report wereverified for accuracy by each hospitalbut were not audited.

What are the CAUTI resultsfor New Jersey for 2010?

There were over 309,000 catheterdays reported to NHSN by NewJersey hospitals in 2010. The for-mula below provides the statewideobserved, expected and SIR forCAUTIs:

Observed CAUTIs = 604Expected CAUTIs = 606.33


The SIR of 1.00 indicates thatCAUTIs for New Jersey is the sameas the expected national data. Thedifference is not statistically signifi-cant. This means the CAUTI inNew Jersey is similar to the CAUTI

seen nationally.

Section 4: Understanding Measures for Healthcare-Associated Infections

Continued on next page


account for the fact that some dif-ferences occur simply due to chance.Although not shown in the table,95% confidence intervals are usedto determine how statistically certainis the conclusion that a hospital’sSIR is higher or lower than 1.0. Formore details, refer to the HAITechnical Report atwww.nj.gov/health/hpr.

A hospital’s SIR is statistically sig-nificantly lower than 1.0 if its 95%confidence interval falls completelybelow 1.0. The hospital is noted withan “L” in the National Comparisoncolumn. This means that fewer HAI

events were observed than expected,adjusting for differences in the typesof patients treated. Since the com-parison is to the national baselinedata, the hospital performed betterthan the national baseline experi-ence.

A hospital’s SIR is statistically sig-nificantly higher than 1.0 if its 95%confidence interval falls completelyabove 1.0. In this case, the hospitalis noted with an “H” in the NationalComparison column. This meansthat more HAI events were observedthan expected, adjusting for differ-ences in the types of patients treatedand that the hospital performedworse than the national baselineexperience.

A hospital’s SIR is not statisticallydifferent from 1.0 if its 95% confi-dence interval includes 1.0. The hos-pital is noted with a an “S” in theNational Comparison column. Thismeans that adjusting for difference

in the types of patients treated, thehospital’s performance on prevent-ing HAI events was similar to thenational baseline experience.

Can we make conclusionsabout a hospital’s perform-ance in preventing HAIsbased on this data?

Please keep in mind some of the fol-lowing issues before making conclu-sions about a hospital. Even thoughhospitals reviewed and verified thedata used in this report, the datahave not been audited by an inde-pendent agency.

It is also important to note that ahospital which performed lower thanthe National Comparison does notnecessarily mean the hospital is bet-ter but that it may need to improveits HAI surveillance protocols.Conversely, a hospital which per-formed higher than the NationalComparison is not necessarily apoor performer. This hospital couldhave better infection control prac-tices and processes institutedthroughout its facility.

In addition, the risk-adjustmentmethod may not fully capture howsick patients are in certain hospitalsand locations. The sicker thepatients are, the more likely a hospi-tal is to have a higher number ofevents. Therefore, it is important touse caution when interpreting thehospital infection data.

What is “NationalComparison”?

In addition to displaying the“observed” and “expected” numbersof events and the SIRs, the tablesinclude a column labeled “NationalComparison.” This column classifiesthe hospitals’ performances as “L”

which is Lower than expected, “S”

which is Similar to expected, or “H”

which is Higher than expected. Ahospital performed better than the

national baseline if the National

Comparison has the letter “L” or

“Lower than Expected”, as indicatedin the table.

In trying to determine a hospital’sperformance, it is important to

Continued from previous page

47A Consumer Report

References

1 Centers for Disease Control andPrevention: Estimates of

Healthcare-Associated Infections.http://www.cdc.gov/ncidod/dhqp/hai

.html accessed January 24, 2011.

2 Scott, RD. The Direct Medical

Costs of Healthcare-Associated

Infections in U.S. Hospitals and

the Benefits of Prevention.

http://www.cdc.gov/HAI/pdfs/hai/

Scott_LostPaper.pdf accessedJanuary 24, 2011.

3 Centers for Disease Control andPrevention: Slides for theAmerican Recovery and

Reinvestment Act Epidemiology

and Laboratory Capacity (ELC)

for Infectious Disease Program,

Healthcare-Associated Infections

(HAIs) Grantee Meeting October19-20, 2009, presented byKatherine Allen-Bridson

http://www.cdc.gov/hai/recoveryAct/

PDF/Oct09/11-

0145_Bridson_NHSN_CLABSI_Da

y2_ Workshop1.pdf accessedJanuary 24, 2011.

4 Centers for Disease Control andPrevention, APIC, JointCommission, IDSA, AHA, SHEA,FAQ Sheet about “Catheter-

Associated Bloodstream

Infections” http://www.cdc.gov/nci-

dod/dhqp/pdf/guidelines/BSI_tagge

d.pdf accessed January 24, 2011.

5 Klevens RM, Edward JR, et al.Estimating health care-associated

infections and deaths in U.S. hos-

pitals, 2002. Public HealthReports 2007; 122:160-166.

6 Edmiston, CE, Spencer, M, Lewis,BD, et al., Reducing the Risk of

Surgical Site Infections: Did We

Really Think SCIP Was Going to

Lead Us to the Promised Land?

Surgical Infections 2011;12(3):169-177.


Central Line-Associated Bloodstream Infections (CLABSIs) 2010

Hospital Name Observed Numberof CLABSIs (O)

Expected Numberof CLABSI (E)a

CLABSI SIRb %

NationalComparison‡

AtlantiCare Regional Medical Center - City 9 8.36 1.08 S

AtlantiCare Regional Medical Center - Mainland 7 9.00 0.78 S

Bayonne Medical Center 2 2.25 0.89 S

Bayshore Community Hospital 3 2.96 1.01 S

Bergen Regional Medical Center 4 1.39 2.88 S

Cape Regional Medical Center 3 2.33 1.29 S

Capital Health System at Fuld 9 9.63 0.94 S

Capital Health System at Mercer 11 5.01 2.20 H

CentraState Medical Center 2 2.82 0.71 S

Chilton Memorial Hospital 1 2.76 0.36 S

Christ Hospital 3 2.17 1.38 S

Clara Maass Medical Center 4 12.99 0.31 L

Community Medical Center 5 3.27 1.53 S

Cooper Hospital/University Medical Center 28 30.69 0.91 S

Deborah Heart and Lung Center 3 6.88 0.44 S

East Orange General Hospital 2 3.97 0.50 S

Englewood Hospital and Medical Center 1 5.1 0.20 S

Hackensack University Medical Center 33 25.07 1.32 S

Hackettstown Regional Medical Center 1 0.74 – –

Hoboken University Medical Center 0 1.45 0 S

Holy Name Hospital 3 3.63 0.83 S

Hunterdon Medical Center 2 3.99 0.50 S

Jersey City Medical Center 5 13.95 0.36 L

Jersey Shore University Medical Center 11 21.80 0.51 L

JFK Medical Center/Anthony M Yelensics 14 15.75 0.89 S

Kennedy University Hospital 4 6.98 0.57 S

Kennedy Memorial Hospitals/UMC-Stratford 1 2.80 0.36 S

Kennedy University Hospital/UMC-Cherry Hill 0 3.17 0 S

Kimball Medical Center 7 2.65 2.64 H

Lourdes Medical Center of Burlington Cty. 0 1.7 0 S

Meadowlands Hospital Medical Center 1 1.03 0.97 S

Memorial Hospital of Salem County 2 0.66 – –

Monmouth Medical Center 6 6.59 0.91 S

Morristown Memorial Hospital 5 17.21 0.29 L

Mountainside Hospital 4 7.29 0.55 S

Newark Beth Israel Medical Center 33 34.56 0.96 S

Newton Memorial Hospital 1 1.64 0.61 S

Ocean Medical Center 5 3.69 1.35 S

Our Lady of Lourdes Medical Center 8 14.83 0.54 S

Overlook Hospital 2 11.95 0.17 L


49A Consumer Report

The Standardized Infection Ratio (SIR) is a summary of the observed(O) or actual number of infections divided by the number of expected(E) events. The SIR allows hospitals to be compared to the nationalexperience. The National Comparison shows how well each hospitalis doing compared to the national experience, a composite of all the

general acute care hospitals in the United States. Data is from 2010and is for adult, pediatric critical/intensive care units and neonatalintensive care units (CCUs or ICUs and NICUs). NOTE: Ratios arenot meant for hospital to hospital comparisons. Lower ratios arebetter and mean fewer CLABSIs.

Source: New Jersey Healthcare-Associated Infections for 2010 submitted through the National Healthcare Safety Network (NHSN).

a Expected (E)= # of infections predicted using risk-adjusted model fitted from the NHSN data from 2006-2008 for CLABSI data. Important to note that if Expected is <1, the SIR is not calculated as the result is not precise.

b Standardized Infection Ratio (SIR)= Observed (O)/ Expected (E)‡ Each hospital is compared to the National Ratio=1. The National Ratio is derived using the CDC's NHSN data from 2006-2008 for CLABSI (AJIC,

December 2009).L indicates hospital infections are LOWER than infections seen nationally.H indicates hospital infections are HIGHER than infections seen nationally.S indicates hospital infections are SIMILAR to infections seen nationally.– SIR is not calculated because the Expected is < 1. Interpret data with caution.

Hospital Name Observed Numberof CLABSIs (O)

Expected Numberof CLABSI (E)a

CLABSI SIRb%

NationalComparison‡

Palisades Medical Center of New York 3 1.26 2.39 S

Raritan Bay Medical Center - Old Bridge 0 2.22 0 S

Raritan Bay Medical Center - Perth Amboy 2 6.03 0.33 S

Riverview Medical Center 5 2.60 1.92 S

Robert Wood Johnson University Hospital 24 35.53 0.68 S

Robert Wood Johnson University Hospital at Hamilton 7 4.88 1.44 S

Robert Wood Johnson University Hospital at Rahway 2 4.27 0.47 S

Saint Barnabas Medical Center 9 29.89 0.30 L

Saint Clare's Hospital - Denville 2 1.33 1.50 S

Saint Clare's Hospital - Dover 1 0.72 – –

Saint Clare's Hospital - Sussex 0 0.12 – –

Saint Michael's Medical Center 11 13.33 0.83 S

Saint Peter's University Hospital 8 15.42 0.52 S

Shore Memorial 5 3.345 1.50 S

Somerset Medical Center 5 4.828 1.04 S

South Jersey Healthcare - Elmer 2 0.76 – –

South Jersey Healthcare Regional Medical Center 0 3.78 0 L

Southern Ocean County Hospital 0 1.69 0 S

St. Francis Medical Center 0 4.99 0 L

St. Joseph's Regional Medical Center 24 23.52 1.02 S

St. Joseph's Wayne Hospital 16 5.01 3.20 H

St. Mary's Hospital 10 5.54 1.81 S

Trinitas Regional Medical Center 3 5.41 0.56 S

UMDNJ - University Hospital 19 18.93 1.00 S

Underwood Memorial Hospital 1 3.43 0.29 S

University Medical Center at Princeton 4 1.54 2.60 S

Valley Hospital 9 12.30 0.73 S

Virtua Marlton 0 4.04 0 L

Virtua-Mem. Hospital of Burlington County 5 4.96 1.01 S

Virtua-West Jersey Health System - Berlin 0 1.43 0 S

Virtua-West Jersey Health System - Voorhees 12 8.09 1.48 S

Warren Hospital 2 1.44 1.39 S

Statewide 436 547.30 0.80 L


Catheter-Associated Urinary Tract Infections (CAUTI) 2010

Hospital Name Observed Number ofCAUTI (O)

Expected Number ofCAUTI (E)a

CAUTI SIRb%

National Comparison‡‡

AtlantiCare Regional Medical Center - City 14 10.36 1.35 S

AtlantiCare Regional Medical Center - Mainland 2 8.90 0.23 L

Bayonne Medical Center 2 3.71 0.54 S

Bayshore Community Hospital 2 3.91 0.51 S

Bergen Regional Medical Center 3 2.72 1.11 S

Cape Regional Medical Center 3 3.03 0.99 S

Capital Health System at Fuld 18 22.73 0.79 S

Capital Health System at Mercer 5 3.81 1.31 S

CentraState Medical Center 4 5.64 0.71 S

Chilton Memorial Hospital 1 3.63 0.28 S

Christ Hospital 6 3.53 1.70 S

Clara Maass Medical Center 9 15.50 0.58 S

Community Medical Center 0 7.64 0 L

Cooper Hospital/University Medical Center 1 26.57 0.04 L


East Orange General Hospital 0 3.64 0 S



Hackettstown Regional Medical Center 0 1.38 0 S

Hoboken University Medical Center 10 2.61 3.84 H


Hunterdon Medical Center 1 5.17 0.19 S

Jersey City Medical Center 2 13.38 0.15 L

Jersey Shore University Medical Center 33 23.31 1.42 S

JFK Medical Center/Anthony M Yelensics 19 13.44 1.41 S

Kennedy University Hospital 20 8.09 2.47 H

Kennedy Memorial Hospitals/UMC-Stratford 7 4.43 1.58 S

Kennedy University Hospital/UMC-Cherry Hill 2 4.84 0.41 S

Kimball Medical Center 5 3.59 1.39 S

Lourdes Medical Center of Burlington Cty. 1 2.72 0.37 S

Meadowlands Hospital Medical Center 0 1.64 0 S

Memorial Hospital of Salem County 3 1.40 2.14 S

Monmouth Medical Center 1 7.99 0.13 L

Morristown Memorial Hospital 12 21.85 0.55 L

Mountainside Hospital 9 8.48 1.06 S

Newark Beth Israel Medical Center 31 18.79 1.65 H

Newton Memorial Hospital 0 3.17 0 S

Ocean Medical Center 3 5.75 0.52 S

Our Lady of Lourdes Medical Center 20 11.31 1.77 H

Overlook Hospital 28 22.93 1.22 S


51A Consumer Report

The Standardized Infection Ratio (SIR) is a summary of the observed(O) or actual number of infections divided by the number of expected(E) events. The SIR allows hospitals to be compared to the nationalexperience. The National Comparison shows how well each hospitalis doing compared to the national experience, a composite of all the

general acute care hospitals in the United States. Data is from 2010and is for adult critical/intensive care units (CCUs or ICUs) only.NOTE: Ratios are not meant for hospital to hospital comparisons.Lower ratios are better and mean fewer CAUTIs.


a Expected (E)= # of infections predicted using risk-adjusted model fitted from the NHSN data from 2009 for CAUTI data. Important to note that if Expected is <1, the SIR is not calculated as the result is not precise.

b Standardized Infection Ratio (SIR)= Observed (O)/ Expected (E)‡‡ Each hospital is compared to the National Ratio=1. The National Ratio is derived using the CDC's NHSN data from 2009 for CAUTI due

to a definition change (AJIC, 2010).L indicates hospital infections are LOWER than infections seen nationally.H indicates hospital infections are HIGHER than infections seen nationally.S indicates hospital infections are SIMILAR to infections seen nationally.– SIR is not calculated because the Expected is < 1. Interpret data with caution.

Hospital Name Observed Number ofCAUTI (O)

Expected Number ofCAUTI (E)a

CAUTI SIRb%


Palisades Medical Center of New York 14 3.00 4.67 H

Raritan Bay Medical Center - Old Bridge 1 2.54 0.39 S

Raritan Bay Medical Center - Perth Amboy 4 5.53 0.72 S

Riverview Medical Center 8 4.82 1.66 S

Robert Wood Johnson University Hospital 44 31.66 1.39 H

Robert Wood Johnson University Hospital at Hamilton 8 4.69 1.70 S

Robert Wood Johnson University Hospital at Rahway 0 0.77 – –

Saint Barnabas Medical Center 8 22.13 0.36 L

Saint Clare's Hospital - Denville 0 2.07 0 S

Saint Clare's Hospital - Dover 0 1.21 0 S

Saint Clare's Hospital - Sussex 1 0.40 – –

Saint Michael's Medical Center 1 13.38 0.08 L


Shore Memorial 4 3.21 1.25 S

Somerset Medical Center 8 9.07 0.88 S

South Jersey Healthcare - Elmer 2 1.46 1.37 S

South Jersey Healthcare Regional Medical Center 5 11.89 0.42 L

Southern Ocean County Hospital 0 4.30 0 L

St. Francis Medical Center 4 5.11 0.78 S


St. Joseph's Wayne Hospital 4 7.94 0.50 S

St. Mary's Hospital 15 6.58 2.28 H

Trinitas Regional Medical Center 6 6.52 0.92 S

UMDNJ - University Hospital 60 33.33 1.8 H

Underwood Memorial Hospital 8 4.60 1.74 S

University Medical Center at Princeton 5 2.68 1.87 S


Virtua Marlton 0 4.41 0 L


Virtua-West Jersey Health System - Berlin 1 1.4 0.71 S


Warren Hospital 3 2.52 1.19 S

Statewide 604 606.33 1.00 S


Overall Surgical Site Infections (SSI) 2009

Hospital Name Observed Number ofOverall SSI (O)

Expected Number ofOverall SSI (E)a

Overall SSI SIRb%

National Comparison‡

AtlantiCare Regional Medical Center - City 0 0.75 – –


Bayonne Medical Center 0 0.05 – –

Bayshore Community Hospital 0 0.11 – –

Bergen Regional Medical Center 0 0.01 – –

Cape Regional Medical Center 0 0.35 – –

Capital Health System at Fuld 0 0.29 – –


CentraState Medical Center 0 0.68 – –

Chilton Memorial Hospital 1 0.61 – –

Christ Hospital 0 0.84 – –

Clara Maass Medical Center 0 0.98 – –

Community Medical Center 3 0.98 – –



East Orange General Hospital 0 0.11 – –




Hoboken University Medical Center 1 0.28 – –


Hunterdon Medical Center 0 0.76 – –

Jersey City Medical Center 0 1.65 0 S


JFK Medical Center/Anthony M Yelensics 0 0.97 – –

Kennedy University Hospital 1 0.70 – –

Kennedy Memorial Hospitals/UMC-Stratford 0 0.09 – –

Kennedy University Hospital/UMC-Cherry Hill 0 0.11 – –

Kimball Medical Center 0 0.34 – –

Lourdes Medical Center of Burlington Cty. 0 0.50 – –

Meadowlands Hospital Medical Center 0 0.27 – –



Morristown Memorial Hospital 15 11.87 1.26 S

Mountainside Hospital 0 0.83 – –


Newton Memorial Hospital 0 0.20 – –

Ocean Medical Center 1 0.33 – –




53A Consumer Report

The Standardized Infection Ratio (SIR) is a summary of theobserved or actual number of events divided by the number ofexpected events. The SIR allows hospitals to be compared tothe national experience. The National Comparison shows how

well each hospital is doing compared to the national experi-ence. Data is from 2009. NOTE: Ratios are not meant for hospital to hospital comparisons. Lower ratios are better and mean fewer HAIs.


a Expected (E)= # of infections predicted using the model fitted from the NHSN data from 2006-2008. This data set will serve as the baseline/benchmark for future reports.

Important to note that if Expected is <1, the SIR is not calculated as the result is not precise.b Standardized Infection Ratio (SIR)= Observed (O)/ Expected (E)‡ Each hospital is compared to the National Ratio=1. The National Ratio is derived using the CDC's NHSN data from 2006-2008

(AJIC, December 2009).L indicates hospital infections are LOWER than infections seen nationally.H indicates hospital infections are HIGHER than infections seen nationally.S indicates hospital infections are SIMILAR to infections seen nationally.– SIR is not calculated because the Expected is < 1. Interpret data with caution.

N/A hospital is not licensed to perform procedure(s) or did not perform procedure(s) in 2009.

Hospital Name Observed Number ofOverall SSI (O)

Expected Number ofOverall SSI (E)a

Overall SSI SIRb%


Palisades Medical Center of New York 0 0.13 – –

Raritan Bay Medical Center - Old Bridge N/A

Raritan Bay Medical Center - Perth Amboy 1 0.39 – –

Riverview Medical Center 0 0.91 – –


Robert Wood Johnson University Hospital at Hamilton 0 0.55 – –


Saint Barnabas Medical Center 4 7.23 0.55 S

Saint Clare's Hospital - Denville 1 0.59 – –

Saint Clare's Hospital - Dover N/A

Saint Clare's Hospital - Sussex N/A



Shore Memorial 0 0.29 – –

Somerset Medical Center 0 0.51 – –


South Jersey Healthcare Regional Medical Center 0 2.03 0 S

Southern Ocean County Hospital 0 0.1 – –

St. Francis Medical Center 0 1.49 0 S


St. Joseph's Wayne Hospital 0 0.29 – –

St. Mary's Hospital 1 1.12 0.89 S

Trinitas Regional Medical Center 6 1.69 3.55 H


Underwood Memorial Hospital 4 0.57 – –

University Medical Center at Princeton 0 0.42 – –


Virtua Marlton 0 0.02 – –


Virtua-West Jersey Health System - Berlin 1 0.07 – –


Warren Hospital 0 0.27 – –

Statewide 127 129.13 0.98 S


Abdominal Hysterectomy Surgical Site Infections 2009

Hospital NameExpected Number of

AbdominalHysterectomyInfections (E)a

SIRb%


Observed Number ofAbdominal

Hysterectomy Infections (O)

AtlantiCare Regional Medical Center - City 0 0.75 – –

AtlantiCare Regional Medical Center - Mainland 0 0.63 – –

Bayonne Medical Center 0 0.05 – –

Bayshore Community Hospital 0 0.11 – –

Bergen Regional Medical Center 0 0.01 – –

Cape Regional Medical Center 0 0.35 – –

Capital Health System at Fuld 0 0.29 – –


CentraState Medical Center 0 0.68 – –

Chilton Memorial Hospital 1 0.61 – –

Christ Hospital 0 0.84 – –

Clara Maass Medical Center 0 0.98 – –

Community Medical Center 3 0.98 – –


Deborah Heart and Lung Center N/A

East Orange General Hospital 0 0.11 – –

Englewood Hospital and Medical Center 1 0.52 – –

Hackensack University Medical Center 0 2.54 0 S


Hoboken University Medical Center 1 0.28 – –


Hunterdon Medical Center 0 0.76 – –

Jersey City Medical Center 0 0.20 – –

Jersey Shore University Medical Center 0 1.82 0 S

JFK Medical Center/Anthony M Yelensics 0 0.97 – –

Kennedy University Hospital 1 0.70 – –

Kennedy Memorial Hospitals/UMC-Stratford 0 0.09 – –

Kennedy University Hospital/UMC-Cherry Hill 0 0.11 – –

Kimball Medical Center 0 0.34 – –

Lourdes Medical Center of Burlington Cty. 0 0.50 – –

Meadowlands Hospital Medical Center 0 0.27 – –



Morristown Memorial Hospital 8 3.36 2.38 H

Mountainside Hospital 0 0.83 – –


Newton Memorial Hospital 0 0.20 – –

Ocean Medical Center 1 0.33 – –

Our Lady of Lourdes Medical Center 0 1.20 0 S



55A Consumer Report

The Standardized Infection Ratio (SIR) is a summary of the observed (O)or actual number of infections divided by the number of expected (E)events. The SIR allows hospitals to be compared to the national experi-ence. The National Comparison shows how well each hospital is doing

compared to the national experience, a composite of all the generalacute care hospitals in the United States. Data is from 2009. NOTE:Ratios are not meant for hospital to hospital comparisons. Lowerratios are better and mean fewer abdominal hysterectomy SSIs.


a Expected (E)= # of infections predicted using the model fitted from the NHSN data from 2006-2008. This data set will serve as the baseline/benchmark for future reports.Important to note that if Expected is <1, the SIR is not calculated as the result is not precise.

b Standardized Infection Ratio (SIR)= Observed (O)/ Expected (E)‡ Each hospital is compared to the National Ratio=1. The National Ratio is derived using the CDC's NHSN data from 2006-2008 (AJIC,

December 2009).L indicates hospital infections are LOWER than infections seen nationally.H indicates hospital infections are HIGHER than infections seen nationally.S indicates hospital infections are SIMILAR to infections seen nationally.– SIR is not calculated because the Expected is < 1. Interpret data with caution.

N/A hospital is not licensed to perform procedure(s) or did not perform procedure(s) in 2009.

Hospital NameExpected Number of

AbdominalHysterectomy Infections (E)a

SIRb%


Observed Number ofAbdominal

Hysterectomy Infections (O)

Palisades Medical Center of New York 0 0.13 – –

Raritan Bay Medical Center - Old Bridge N/A

Raritan Bay Medical Center - Perth Amboy 1 0.39 – –

Riverview Medical Center 0 0.91 – –

Robert Wood Johnson University Hospital 6 1.17 5.12 H

Robert Wood Johnson University Hospital at Hamilton 0 0.55 – –


Saint Barnabas Medical Center 4 2.30 1.74 S

Saint Clare's Hospital - Denville 1 0.59 – –

Saint Clare's Hospital - Dover N/A

Saint Clare's Hospital - Sussex N/A

Saint Michael's Medical Center 0 0.40 – –


Shore Memorial 0 0.29 – –

Somerset Medical Center 0 0.51 – –


South Jersey Healthcare Regional Medical Center 0 2.03 0 S

Southern Ocean County Hospital 0 0.1 – –

St. Francis Medical Center 0 0.05 – –

St. Joseph's Regional Medical Center 0 0.86 – –

St. Joseph's Wayne Hospital 0 0.29 – –

St. Mary's Hospital 0 0.24 – –

Trinitas Regional Medical Center 6 1.69 3.55 H


Underwood Memorial Hospital 4 0.57 – –

University Medical Center at Princeton 0 0.42 – –


Virtua Marlton 0 0.02 – –


Virtua-West Jersey Health System - Berlin 1 0.07 – –


Warren Hospital 0 0.27 – –

Statewide 71 58.87 1.21 S


The Standardized Infection Ratio (SIR) is a summary of the

observed (O) or actual number of infections divided by the

number of expected (E) events. The SIR allows hospitals to

be compared to the national experience. The National

Comparison shows how well each hospital is doing com-

pared to the national experience, a composite of all the gen-

eral acute care hospitals in the United States. Data is from

2009.

Only 18 of the 72 acute care hospitals are licensed as

Open Heart Surgery hospitals and are able to perform

CABG surgery.

NOTE: Ratios are not meant for hospital tohospital comparisons. Lower ratios are betterand mean fewer CABG SSIs.


a Expected (E)= # of infections predicted using the model fitted from the NHSN data from 2006-2008. This data set will serve as the baseline/benchmark for future reports.Important to note that if Expected is <1, the SIR is not calculated as the result is not precise.

b Standardized Infection Ratio (SIR)= Observed (O)/ Expected (E)‡ Each hospital is compared to the National Ratio=1. The National Ratio is derived using the CDC's NHSN data from 2006-2008 (AJIC, December 2009).L indicates hospital infections are LOWER than infections seen nationally.H indicates hospital infections are HIGHER than infections seen nationally.S indicates hospital infections are SIMILAR to infections seen nationally.– SIR is not calculated because the Expected is < 1.

CABG: includes procedures with either chest only or chest and donor site incisions.

Coronary Artery Bypass Graft (CABG) Surgical SiteInfections 2009

Hospital Name Observed Number ofCABG Infections (O)

Expected Number ofCABG Infections (E)a

SIRb%







Jersey City Medical Center 0 1.45 0 S


Morristown Memorial Hospital 7 8.50 0.82 S




Saint Barnabas Medical Center 0 4.93 0 L


St. Francis Medical Center 0 1.44 0 S


St. Mary's Hospital 1 0.89 – –

UMDNJ - University Hospital 0 0.67 – –


Statewide 56 70.26 0.80 S

What are hospitals doingto prevent SSIs aftersurgery?

Doctors, nurses and otherhealthcare providers must:

D Clean their hands and arms upto the elbows with an antisepticjust before the surgery.

D Clean their hands with soap andwater or an alcohol-based handrub before and after caring foreach patient.

D Remove the patient’s hairimmediately before surgeryusing electric clippers if the hairis in the same area where theprocedure will occur. Theyshould not use a razor.

D Wear hair covers, masks, gowns,and gloves during surgery tokeep the surgery area clean.

D Provide antibiotics beforesurgery starts, usually within 60minutes and stop antibioticswithin 24 hours after surgery.

D Clean the skin at the surgerysite with a special soap that killsgerms.

What can I do to helpprevent an SSI?

D Make sure those caring for youclean their hands with soap and

water or an alcohol-based hand rubbefore and after caring for you.

D Always clean your hands before andafter caring for your wound.

D Family and friends who visit youshould not touch the surgicalwound or dressings.

D Visitors should clean their handswith soap and water or an alcohol-based hand rub before and aftervisiting you.

D If you have any symptoms of aninfection such as redness and painat the surgery site, drainage, orfever, call your doctor immediately.

What if I get an SSI? Canit be treated?

D Yes. Most surgical site infectionscan be treated with antibiotics.The antibiotic given depends onthe bacteria (germs) causing theinfection. Sometimes patients withSSIs also need another surgery totreat the infection.

See Patient Safety Tips for Surgery

on page 64 and Basic Facts on

Surgical Care Improvement Project

(SCIP) on pages 20-21 for more

information.

Preventing Surgical Site Infections (SSI)

lthough most patients having surgery will do fine, 1 to 3 out of 100 patients will get infections aftersurgery. These infections can make recovery fromsurgery more difficult because they can cause

additional illness, stress, and cost. Adhering to certainstandard procedures can help prevent acquiring an infectionafter surgery. The following are tips from the Centers forDisease Control and Prevention (CDC).

A

57A Consumer Report

Remember: If you do not seeyour providers clean their hands,please ask them to do so.


What do hospitals advisenurses and doctors to doto prevent CLABSI?

D Choose a vein where the cathetercan be safely inserted and wherethe risk for infection is small.

D Clean their hands with soap andwater or an alcohol-based handrub before putting in thecatheter.

D Wear a mask, cap, sterile gown,and sterile gloves when putting inthe catheter to keep it sterile.The patient will be covered witha sterile sheet.

What can I do to helpprevent a CLABSI?

D Ask your doctors and nurses toexplain why you need the catheterand how long you will have it.

D Ask your doctors and nurses ifthey will be using all of theprevention methods discussedabove.

D Make sure that all those caring foryou clean their hands with soapand water or an alcohol-basedhand rub before and after caringfor you.

D Tell your nurse or doctorimmediately if the bandage comesoff or becomes wet or dirty.

D Inform your nurse or doctor if thearea around your catheter is sore orred.

D Do not let visitors touch thecatheter or the tubing.

D Make sure family and friendsclean their hands with soap andwater or an alcohol-based handrub before and after visiting you1.

Preventing Central Line-Associated Bloodstream Infections

Central Line-Associated Bloodstream Infection(CLABSI) is serious, but often can be successfullytreated with antibiotics. The central line (i.e., catheter)might need to be removed if a patient develops an

infection. Below is a summary of steps to follow to helpprevent CLABSIs from occuring. The following are tips fromthe Centers for Disease Control and Prevention (CDC).A

D Clean the patient’s skin with anantiseptic cleanser before putting inthe catheter.

D Clean their hands, wear gloves, andclean the catheter opening with anantiseptic solution before using thecatheter to draw blood or givemedications.

D Clean their hands and wear gloveswhen changing the bandage thatcovers the area where the catheterenters the skin.

D Decide every day if the patient stillneeds to have the catheter. Thecatheter will be removed as soon asit is no longer needed1.


What causes CAUTI?

If germs get into the urinary tract,they can cause an infection. Thegerms that cause the infection inthe bladder are usually found inthe intestines, where they are notharmful. Germs can enter theurinary tract when the catheter isbeing inserted or while it is in thebladder.

What are the symptomsof a urinary tractinfection?

D Burning or pain below thestomach (called the lowerabdomen)

D Fever

D Bloody urine

D Burning during urination or anincrease in the frequency ofurination after the catheter isremoved.

D Sometimes there are nosymptoms.

Can CAUTI be treated?

Most CAUTIs can be treated withantibiotics and by removing orchanging the catheter. Yourdoctor will determine the bestantibiotic for you.

How can I help preventCAUTI?D Ask your healthcare provider to

clean the area where the catheter isto be inserted before its insertion.

D Make sure your healthcare providerremoves any temporary cathetersused to drain the urine right away.This temporary catheter is calledintermittent urethral catheterization.

D Avoid twisting, kinking ordisconnecting the catheter and thedrain tube. Doing so could exposethe tube to germs.

D Keep the bag lower than thebladder to prevent the urine fromflowing back into the bladder.

D Make sure the bag is emptiedregularly. When this is done, thedrainage spout should not touchanything.

D Ask your provider every day if youstill need the catheter. Cathetersare inserted only when necessaryand should be removed as soon aspossible.

More About Catheter-Associated Urinary Tract Infections(CAUTI) and How to Prevent Them

Catheter-Associated Urinary Tract Infection(CAUTI) is the most common form of Healthcare-Associated Infection (HAI) reported in hospitals. Theurinary catheter, which is a thin tube placed in the

bladder, drains the urine through the tube into a bag. Thecatheter is secured to the leg to prevent pulling on it.

People with urinary catheters have a much higher chance ofgetting a urinary tract infection than those who don’t. It is,therefore, important to understand what CAUTI is and whatyou can do to prevent it from occurring. The following aretips from the Centers for Disease Control and Prevention(CDC).

A

59A Consumer Report

Remember: If you do not seeyour providers clean theirhands before and after touchingyour catheter, please ask themto do so.


What is the right way towash your hands?

D Wet your hands with clean,running water. It can be warmor cold. Apply soap, enough tolather. Washing your handswith soap and water is the bestway to reduce germs on them.

D Rub your hands together toform a lather; scrub the backsof your hands, between yourfingers, under your nails as wellas the palms of your hands.

D Before and after touchingsomeone who is sick.

D Before and after treating a cut orwound.

D After using the toilet.

D After changing diapers or cleaningup a child who has used the toilet.

D After blowing your nose, coughing,or sneezing.

D After touching an animal oranimal waste.

D After touching garbage.

What if you don’t havesoap and/or clean, runningwater?

D If you don’t have soap and water,use an alcohol-based handsanitizer that contains at least60% alcohol.

In some instances, sanitizers canreduce the number of germs onyour hands but do not eliminateall types of germs. Handsanitizers are not effective onhands that are very dirty.

Handwashing Helps Prevent Infections

any diseases and infections are spread throughthe hands. Even if your hands or your doctor,nurse or caregiver’s hands look clean, they maybe carrying germs or bacteria unless they are

properly cleaned. And yes, there is a right way to wash yourhands. The Centers for Disease Control and Prevention(CDC) recommends the following:M

D Rub your hands for at least 20seconds. If you don’t have a timer,sing the“happy birthday to you” songtwice from beginning to end.

D Rinse your hands well under runningwater.

D Dry your hands with a clean towel orair dry them.

When should you wash yourhands?

D Before, during and after preparingfood.

D Before eating food.


Section 5

Consumer Information

D Taking an Active Role in Your Health Care

D Patient Safety Tips for Surgery

D Finding a Doctor or Information on Your Doctor

D Health Information and Referral

D Hospital Patients…Know Your Rights

D Health Care Quality Oversight

D Filing a Complaint

D Quality Improvement

Advisory Committee C

onsu

mer

Info

rmati

on


Taking an Active Role in Your Healthcare

Take responsibility for your health care by making decisions carefully and learning about your medicalcondition and treatment options.

Manage Your MedicationsSafely

Ask the pharmacist if the medicine iswhat your doctor prescribed.

Ask both your doctor and yourpharmacist to tell you about yourmedication in understandable terms:

D What is the purpose of themedicine?

D How am I supposed to take the medicine and for how long?

D What side effects are likely? Whatdo I do if they occur?

D Is this medicine safe to take withmy other medicines or dietarysupplements?

D What food, drink or activitiesshould I avoid while taking thismedicine?

Read the labels and inserts of themedication to learn about sideeffects and warnings. If you have anyquestions about the instructions, ask.

Use the same pharmacy or pharmacychain for all medications, if possible.

Make sure all your doctors know allthe medication and supplements youare taking:

• Make a list and bring it with youif you are entering the hospital.

• If you are not being admitted tothe hospital, bring the list to yourdoctor at least once a year.

• Include non-prescriptionmedicines, herbal remedies anddietary supplements, such asvitamins.

• Show the list to your doctor,surgeon, hospital pharmacist andhospital staff.

• No time to make a list? Bring themedications and keep them intheir containers.

Inform your doctors, pharmacist andhospital personnel about any existingdrug allergies.

Ask a health care professional aboutthe purpose and dosage of your IVsolution if it is being administered orreplaced.

Get the Results of all Testsand Procedures

Call your doctor and ask for yourresults, whether they are taken in thehospital or in your doctor’s office.Don’t assume that the results are fineif you do not receive a follow-up call.

Ask questions about the results andwhat they mean.

Know Your TreatmentOptions

Understand what your doctor is tellingyou about your medical condition.

Learn as much as you can. Yourdoctor and/or library can help youfind reliable information.

Ask your doctor to explain all of youralternative treatments and non-surgical options, including thepotential risks of each one.

Consider getting a second opinion andweigh the possible outcomes of eachtreatment option.

Choose a hospital that has treatedmany patients with your condition orthe surgery you need. Patients havebetter results when they are treated inhospitals that have had a lot ofexperience treating their condition.

63A Consumer Report

Section 5: Consumer Information

When in the Hospital

Think about using a health advocateto ask questions, write downinformation and speak up for you soyou can get the care and resourcesyou need. A health advocate can befamily, a friend, or a hiredprofessional. Some hospitals employpatient advocates.

Consider asking all health careworkers that have direct contact withyou if they have washed their hands.Hand washing prevents the spread ofinfections. (See Handwashing Helps

Prevent Infections on page 60).

Ask your doctor whether he/she willbe visiting you in the hospital orwhether there will be a hospitalist

instead. Many hospitals are hiringhospitalists to provide around theclock inpatient care and substitute foryour personal physician.

Find out which hospital staff willdevelop your care plan.

D Who will be leading this function?D How often will they meet to

discuss your needs?D How often will information be

communicated to you and yourfamily?

Understand the treatment plan youwill use at home.

D Learn about your medications. D Find out when you can resume

regular activities.D What kind of follow-up care will

you require?D Will the hospital assist you in

finding someone to help with your

care at home?D What training will the hospital

provide to continue your treatmentat home?

D Ask for copies of results of medicaland lab tests taken while in thehospital.

Take Charge

Take care of your health with regularappointments for routine check-upsand preventive care.

Talk to your doctor about when youneed preventive health screenings.

Create a healthy lifestyle by eatingright, exercising and getting theproper amount of sleep.

Keep a written record of your healthhistory in one place. Check outAARP’s web page,http://assets.aarp.org/external_sites/

caregiving/homecare/health_history.

html, for more information.

Be prepared in case of emergencies.Prepare a Living Will or a HealthProxy, a legal document thatdescribes how you want to be treatedin case you are incapacitated or neardeath.

Discuss your wishes for end-of-lifetreatment with your primary healthprofessional and loved ones. Seehttp://www.ohsu.edu/polst/index.htm

for Physician Orders for LifeSustaining Treatment (POLST).

Learn your rights and responsibilitieswhen in the hospital.

See Patient Rights Section

on page 68.


Patient Safety Tips for Surgery

D What are my options for the

best place to have this type ofsurgery: in the office, same-

day surgery center or hospital?

Consider cost, your health plancoverage, and above all, safetyfactors. Ask which of theseoptions is the usual way thesurgery is done?

D What exactly do you expect will

be done during surgery?

Be sure that you, your doctor andyour surgeon agree on exactlywhat will be done during surgery,and you are aware of what toexpect.

D Are the surgeon,anesthesiologist and nursesaware of any allergies orprevious bad reactions toanesthesia that you may havehad?

Don’t assume they know whatyou are allergic to, especially ifyou have not told them. If youhave already told them, remindthem.

D Can I continue to takemedications and vitamins that Iam routinely taking?

Inform all your doctors and nursingstaff about all the prescriptionmedications, vitamins, herbalsupplements, and over-the-countermedications you are currentlytaking. Certain combinations ofmedicines can lead to problems.Patients taking heart medicationneed to be careful that thecombinations will not lead to aheart attack.

D Should I wash with an antibioticsoap the day before surgery?

If you are supposed to wash withan antibiotic soap, ask thedoctor to show you how. Doingso may help prevent infections.

D Will I need an antibiotic beforesurgery? If so, for how long?

Antibiotics should be takenwithin 1 hour before surgery andstopped within 24 hours in mostcases, lowering your risk ofinfection after surgery.

To make your surgery safer, consider asking your doctor(s), nurse(s) and clinical staff some of the followingquestions before surgery:

D If hair has to be removed frommy body before surgery, willyou be using clippers ratherthan a razor?

Razors can cause infections ifthey leave small cuts on theskin.

D What will you do to prevent the risk of blood clots?

Because you do not movewhile under anesthesia, bloodclots can form, possiblyleading to a heart attack and astroke. The more complicatedthe surgery, the higher therisk. A doctor may give youmedication or a compressiondevice/stocking to reduce yourchances of forming a bloodclot or recommend anothertreatment. Ask your doctorwhat treatment is right foryou.

Have the Surgeon Markthe Site He or She WillOperate On

Don’t be afraid to ask yoursurgeon to mark the site on yourskin to be operated on the day ofsurgery. Request that thesurgeon to use an indeliblemarker (ink that will not easilywash off). Although it is rare,surgeons can make a mistake andoperate on the wrong part of thebody. Marking the correct sitewill help prevent this uncommonmedical error.

65A Consumer Report

Finding a Doctor

What to Look for in a DoctorD Look for a doctor that has

experience in treating yourcondition. Call the doctor’s officestaff and ask them questionsbefore you make an appointment.

D You may want a doctor who hasprivileges (is permitted to practice)at a particular hospital. Narrowyour search by looking at justthose doctors with admittingprivileges to this hospital.

D Get information about the doctor’straining and hospital affiliations.Find out if the doctor is boardcertified in his/her specialty area."Certified" means that the doctorhas completed a training programin a specific specialty. Whileboard certification is a goodmeasure of a doctor's knowledge,you can receive quality care fromdoctors who are not boardcertified.

Use the web sites listed in thissection or call the doctor’s officestaff to get the answers. You canalso call the American Board ofMedical Specialties at (866) 275-2267 to find out if the doctor isboard certified.

D Find out if there are anydisciplinary actions against thedoctor by contacting the NJHealthcare Profile through theirweb site at www.NJdoctorlist.com.

D Ask about the doctor’s officehours, back-up coverage to handleemergencies and how quickly youcan make an appointment bycalling the doctor’s office staff.

D Make sure that you like yourdoctor and are at ease talking tohim/her. If you do not like yourdoctor or do not trust him/her,you will not be able to discussyour health issues comfortablyand communicate freely. Thisalso means that you should beable to ask questions and clarifyanything you do not understand.

For more tips, check out the Agency for Health Care Quality andResearch (AHRQ’s) web site,http://www.ahrq.gov/questions/gb.

Choose a Doctor Carefully

D Ask your insurer for a list ofphysicians in its network. Someinsurers will not reimburse you forvisits to doctors outside theirnetwork, and others may partiallyreimburse you.

D Ask friends, family, co-workers andneighbors for recommendations.

D Call the doctor referral service ata hospital of your choice and askthem for a list of physicians withinthe specialized area you areseeking. Keep in mind that theywill only provide a list of doctorson their staff and will not makeany recommendations.

Use the following web sites tofind a doctor or to find outinformation about a doctor:

D New Jersey HealthcareProfile: www.NJdoctorlist.com helps you find doctorsby location or field of medicine.Review a doctor’s credentials,background, disciplinaryactions and malpracticepayments.

D DoctorFinder:http://extapps.ama-assn.org/doctorfinder/ anAmerican Medicine Association(AMA) web site, provides officeaddresses, phone numbers, andboard certifications on over814,000 doctors in the US.Search by name, specialty,hospital, or county.

D Physician and Other HealthCare Professional Directory:http://www.medicare.gov/find-a-doctor/provider-search.aspx gives thespecialties, office locations,maps, directions, and phonenumbers of doctors whoprovide services to Medicarepatients. Doctors’ profilesmay also include theireducation, gender, residency,languages, and hospitalaffiliation.

Searching for a doctor can be confusing. Below are some suggestions tohelp you find a doctor and choosing the right one for you:

To make your surgery safer, consider asking your doctor(s), nurse(s) and clinical staff some of the followingquestions before surgery:

Health Information Referral

D Asthma Information and Resources (DHSS): NJ asthma programs and resources. www.nj.gov/health/

fhs/asthma

D Pediatric and Adult Asthma Programs (PACNJ): Asthma programs and services in NJ. (908) 685-8040ext. 320 or www.pacnj.org

D Resources on Allergy, Asthma, and Immunology (AAAAI): Asthma and allergy related information.(414) 272-6071 or www.aaaai.org

D Cancer Control and Prevention (DHSS): Various types of cancer resources by NJ county.www.nj.gov/health/ccp

D Cancer Initiatives (DHSS): State and federal resources, research, data, treatment and prevention.www.nj.gov/health/cancer

D Cancer Resources (ACS): Comprehensive information on cancer. (800) 227-2345 or www.cancer.org

D Resources for Cancer Patients in New Jersey (NJCCR): Information, resources, and support grouplocations. www.nj.gov/health/ccr/patientresources.htm

D Cardiac Surgery in New Jersey (DHSS): Coronary artery bypass graft surgery (CABG) death rates for NJhospitals and physicians. www.nj.gov/health/healthcarequality/documents/cardconsumer08.pdf

D Heart Health (AHA): A wide range of cardiovascular and stroke topics. (800) 242-8721 orwww.americanheart.org

D Healthy Lungs (ALA): Fighting and preventing lung disease, such as asthma, smoking, environmentalhealth, and research. (800) 586-4872 or www.lungusa.org

D Diabetes Information (ADA): Information on diabetes. (800) 342-2383 or www.diabetes.org

D Diabetes Prevention and Control (DHSS): Diabetes resources, information, NJ data, and treatment.(609) 984-6137 or www.nj.gov/health/fhs/diabindex.shtml

D Diabetes and Me (CDC): From the basics to research, statistics, and educational publications. (800) CDC-INFO; TTY (888) 232-6348 or www.cdc.gov/diabetes/consumer/index.htm

D Diagnosis/Treatment of Diseases (ACS, ADA, AHA, AACR): Current research on diagnosis andtreatment of specific diseases. www.PatientInform.com

D Health Conditions (CDC): Disease prevention and control, environmental health, and health promotion.www.cdc.gov

D Health Data Fact Sheets (DHSS): Selected NJ health topics. www.nj.gov/health/chs/index.html

D Health Issues (NLM, NIH): Various conditions, health news, clinical trials, medicines, encyclopedias andmedical dictionary. www.medlineplus.gov

These resources provide a good starting point in finding out how to get the best health care.

Health Care Conditions

&

66 Hospital Performance Report 2011

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D Medicare and You/MyMedicare.gov (CMS): Health and drug plan options; benefits,enrollment, eligibility and preventive health. (800) MEDICARE orhttp://www.medicare.gov/Publications/Pubs/pdf/10050.pdf

D Medicare Preventive Services (CMS): Preventive information and services available toMedicare recipients. (800) MEDICARE orhttp://www.medicare.gov/Publications/Pubs/pdf/10110.pdf

D Medicines and You: A Guide for Older Adults (FDA): Importance of knowing yourmedicines to avoid problems. http://www.fda.gov/Drugs/ResourcesForYou/ucm163959.htm

D NIHSeniorHealth.gov (NIA, NLM, NIH): Authoritative and up-to-date health andwellness information. www.nihseniorHealth.gov

D NJEASE (DHSS): One telephone call to find NJ programs and benefits for seniors. (877)222-3737 or www.nj.gov/health/senior/sanjease

D Talking With Your Doctor: A Guide for Older People (NIA): How to discuss healthconcerns and medicines with physicians. (800) 222-2225; TTY (800) 222-4225 orwww.nia.nih.gov/health/publication/talking-your-doctor-guide-older-people

D Everyday Choices for a Healthier Life Style (ACS, ADA, AHA): Disease preventionand early detection. www.everydaychoices.org

D Healthfinder.gov: Health information from the federal government and otherresources. www.healthfinder.gov

D Hospital and Consumer Information (Joint Commission): Find accredited hospitals,disease specific hospitals for treatment and learn how to find reliable health information onthe internet. www.JointCommission.org/general_public.aspx

D NJ HMO Performance Report (DOBI): Performance comparisons of NJ’s managedcare plans and consumer ratings. www.nj.gov/dobi/lhactuar.htm #hmo

D NJ Prescription Drug Retail Price Registry (LPSCA): Compare drug retail pricescharged by pharmacies. (800)-242-5846. www.njdrugprices.nj.gov

D Preventive Care Booklets (AHRQ): Guides to healthy habits, screening tests, andimmunizations. (800) 358-9295 l Men: Stay Healthy at Any Age. www.ahrq.gov/ppip/healthymen.html Women: Stay Healthy at Any Age. www.ahrq.gov/ppip/healthywom.htm

AAAAI:American Academy of Allergy,

Asthma and Immunology

AACR:American Association for

Cancer Research

ACS: American Cancer Society

ADA: American Diabetes Association

AHA: American Heart Association

AHRQ: Agency for Healthcare

Research and Quality

ALA: American Lung Association

CDC: Centers for Disease Control

and Prevention

CMS: Centers for Medicare and

Medicaid Services

DHSS: NJ Department of

Health and Senior Services

DOBI: NJ Department of Banking and

Insurance

FDA: Food and Drug Administration

LPSCA: NJ Law and Public Safety,

Consumer Affairs

NIA: National Institute on Aging

NIH: National Institutes of Health

NJCCR: NJ Commission on Cancer

Research

NJEASE: New Jersey Easy Access,

Single Entry

NLM: National Library of Medicine

PACNJ: Pediatric/Asthma Coalition of NJ

Seniors

Preventive Care and General Health Information

KEY

67A Consumer Report

D Questions are the Answer (AHRQ): Asking questions can improve your health and increase communication with health care professionals. www.ahrq.gov/consumer/qntool.htm


Hospital Patients . . . Know Your Rights

As a patient in a New Jersey hospital, you have the right to:

Medical Care

D Receive an understandableexplanation from your physicianof your complete medicalcondition including recommendedtreatment, expected results, risksand reasonable alternatives. Ifyour physician believes that someof this information would bedetrimental to your health orbeyond your ability to understand,the explanation must be given toyour next of kin or guardian.

D Give informed written consentprior to the start of specified, non-emergency medical procedures ortreatments only after yourphysician has explained - in termsyou can understand - specificdetails about the recommendedprocedure or treatment, the risks,time to recover and reasonablemedical alternatives.

D Be informed of the hospital’swritten policies and proceduresregarding life-saving methods andthe use or withdrawal of life-support.

D Refuse medication and treatmentto the extent permitted by law andto be informed of the medicalconsequences of refusal.

D Be included in experimentalresearch only when you have giveninformed consent to participate.

D Choose your own privateprofessional nurse and contractdirectly for this care duringhospitalization. You can requestfrom the hospital a list of localnon-profit professional nursesassociation registries that refernurses.

D Receive appropriate assessmentand treatment for pain.

Transfers

D Be transferred to another facilityonly if the current hospital isunable to provide the level ofappropriate medical care or if thetransfer is requested by you oryour next of kin or guardian.

D Receive from a physician inadvance an explanation of thereasons for transfer includingalternatives, verification ofacceptance from the receivingfacility, and assurance that themove will not worsen yourmedical condition.

Communication andInformationD Be treated with courtesy,

consideration and respect foryour dignity and individuality.

D Know the names and functions ofall physicians and other healthcare professionals directly caringfor you.

D Expeditiously receive the servicesof a translator or interpreter, ifneeded, to communicate with thehospital staff.

D Be informed of the names, titles,and duties of other health careprofessionals and educationalinstitutions that participate inyour treatment. You have theright to refuse to allow theirparticipation.

D Be advised in writing of thehospital’s rules regarding theconduct of patients and visitors.

D Receive a summary of your rightsas a patient, including the name(s)

69A Consumer Report


and phone number(s) of thehospital staff to whom to directquestions or complaints aboutpossible violations of your rights.If at least 10% of the hospital’sservice area speaks your nativelanguage, you can receive a copyof the summary in your nativelanguage.

Medical Records

D Have prompt access to yourmedical records. If yourphysician feels that this access isdetrimental to your health, yournext of kin or guardian has aright to see your records.

D Obtain a copy of your medicalrecords at a reasonable feewithin 30 days after submitting awritten request to the hospital.

Cost of Hospital Care

D Receive a copy of the hospitalcharges, an itemized bill, ifrequested, and an explanation.

D Appeal any charges and receivean explanation of the appealsprocess.

D Obtain the hospital’s help insecuring public assistance andprivate health care benefits towhich you may be entitled.

Discharge Planning

D Be informed about any need forfollow-up care and receiveassistance in obtaining this carerequired after your dischargefrom the hospital.

D Receive sufficient time beforedischarge to arrange for follow-up care after hospitalization.

D Be informed by the hospital aboutthe discharge appeal process.

Privacy and Confidentiality

D Be provided with physical privacyduring medical treatment andpersonal hygiene functions, unlessyou need assistance.

D Be assured confidentiality aboutyour patient stay. Your medicaland financial records shall not bereleased to anyone outside thehospital without your approval,unless you are transferred toanother facility that requires theinformation, or release of theinformation is required andpermitted by law.

D Have access to individual storagespace for your private use and tosafeguard your property if unableto assume that responsibility.

Freedom from Abuse andRestraints

D Be free from physical and mentalabuse.

D Be free from restraints unlessauthorized by a physician for alimited period of time to protectyour safety or the safety of others.

Civil Rights

D Receive treatment and medicalservices without discriminationbased on race, age, religion,national origin, sex, sexualpreferences, handicap, diagnosis,ability to pay or source ofpayment.

D Exercise your constitutional, civiland legal rights.

Questions, Complaints andAppeals

D Ask questions or file grievancesabout patient rights with adesignated hospital staff memberand receive a response within areasonable period.

D Be provided, by the hospital, withcontact information for the NewJersey Department of Health andSenior Services unit that handlesquestions and complaints.

See To File a Complaint on page 71

for details.


Hospital Quality Oversight

In addition to this performance report, the New Jersey Department of Health and Senior Services (DHSS)monitors quality in New Jersey hospitals in other forms.

New Jersey Department ofHealth and Senior Services(DHSS) The Department’s oversight activitiesare intended to promote the health,safety and welfare of patients/residents in New Jersey health carefacilities.

Licensure:

DHSS issues licenses to hospitals,ambulatory care and other health carefacilities. You can access the names,addresses, licensure expiration datesand other information on the hospitalslicensed by DHSS by visitingwww.nj.gov/health/healthfacilities/

search/ac.shtml.

Inspections:

To evaluate compliance with Stateregulatory standards, the Departmentconducts facility inspections and alsoresponds to specific complaints. Inaddition, the Department conductsinspections under contract to the U.S.Department of Health and HumanServices to evaluate facility compliancewith Medicare conditions ofparticipation.

Enforcement:

If a hospital does not meet Statelicensure or Medicare standards, theDepartment may cite the hospital for adeficiency, and the hospital must

submit a plan of correction. In the caseof licensure standards violations, theDepartment may also issue a monetarypenalty or take other actions.

Patient Safety DHSS oversees several initiatives thatensure the safety of inpatients in NewJersey hospitals,

D The Patient Safety Reporting

System is responsible for collectingconfidential information onmedical errors from hospitals andensuring that hospitals review theseevents to prevent reoccurrence.

D The Patient Safety Indicators

(PSIs) are a data set developed bythe Agency for Health CareResearch and Quality (AHRQ)that measure the extent to whichcertain avoidable medical errorsoccur in each hospital. Recentlegislation has mandated thatDHSS publicly report thisinformation for NJ hospitals. Theresults of the data can be found onpages 36-40 of this report. Moredetail can be found on the web atwww.nj.gov/health/hpr.

71A Consumer Report

Filing a Complaint Section 5: Consumer Information

Treated You:About a New Jersey Hospital and how it:

About a New Jersey Physician:

About a New Jersey Nurse:

Handled Your Application for CharityCare:

Billed You and YouAre Covered By aNew Jersey Health Maintenance Organization:

Billed You andYou Are Enrolledin Medicare:

Billed You andYou Are Enrolledin Medicaid:

Write... New Jersey Board of Medical Examiners, PO Box 183 Trenton, NJ 08625-0183

Visit... www.njconsumeraffairs.gov/bme/bmeform.htm

Call... New Jersey Board of Medical Examiners at (609) 826-7100to obtain a complaint form

Write... New Jersey Board of Nursing, PO Box 45010, Newark, NJ 07101

Call... New Jersey Board of Nursing at (973) 504-6457

Write... New Jersey Department of Health and Senior Services,Division of Health Facilities Evaluation and Licensing,Office of Health Facilities Assessment and Survey; PO Box367; Trenton, NJ 08625-0367

Visit... www.nj.gov/health/healthfacilities/hotlines.shtml

Call... Complaint hotline at (800) 792-9770

Write... New Jersey Department of Health and Senior ServicesNew Jersey Hospital Care Payment Assistance ProgramPO Box 360, Trenton, NJ 08625-0360

Call... New Jersey Hospital Care Payment Assistance Program at (866) 588-5696

Email... [email protected]

Write... Department of Banking and Insurance, Consumer Protection Services, Managed Care Complaints and Appeals, PO Box 329 20 West State Street, 9th floor, Trenton, NJ 08625-0329

Visit... www.state.nj.us/dobi/mcfaqs.htm

Call... Office of Managed Care at (888) 393-1062

Visit... Medicare Program at www.medicare.gov

Call... Medicare Program at (800) MEDICARE

Call... Medicaid hotline at (800) 356-1561


Quality Improvement Advisory Committee (QIAC)

Maureen Bueno, RN, PhD Co-ChairQualCare Inc.

Peter A. Gross, MD Co-ChairHackensack University MedicalCenter

Fred M. Jacobs, MD, JDCo-ChairSaint Barnabas Health Care System

Joshua Bershad, MD, MBARWJ University Hospital

Joel Cantor, ScDCenter for State Health PolicyRutgers University

Donald E. Casey, Jr., MDAtlantic Health System

Lawrence Downs, Esq.Medical Society of New Jersey

Bernie Gerard, Jr.Health Professionals and AlliedEmployees

Aline HolmesNew Jersey Hospital Association

Suzanne IanniHospital Alliance of NJ

David KnowltonNJ Health Care Quality Institute

Mary LawAtlantiCare Regional MedicalCenter

Frank Lumia, MDHealth Care Consultant

Maureen McKeeNJ Council of Teaching Hospitals

Michael MutterValley Health System

Barbara Niedz, PhDAPS Healthcare

Pamela R. OrtonNJ Department of Human Services

David PointerNJ Public Employees State HealthBenefits Program

Joyce G. PontbriandHealthcare Quality Strategies, Inc.

Valerie ReelsHackensack University MedicalCenter

Joel Reichman, MDLourdes Medical Center ofBurlington County

QIAC is an advisory committee for the NJ Department of Health and Senior Services (DHSS) thatprovided advice on developing this report.

Wardell SandersNJ Association of HealthPlans

Molly SullivanCapital Health System

Tom Westover, MDCooper Hospital/UniversityMedical Center

DHSS Staff

Cynthia KirchnerDirector, Quality

Improvement

Emmanuel NoggohDirector

Markos Ezra Letitia Holloway-OwensJianping Huang Juana JacksonMarcia Jaffe Abate Mammo

Section 6

New Jersey General Acute CareHospitals

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New Jersey General Acute Care Hospitals

AtlantiCare Regional MedicalCenter–City Division1925 Pacific AvenueAtlantic City, NJ 08401(609) 344-4081www.atlanticare.org

AtlantiCare Regional MedicalCenter–Mainland DivisionJimmie Leeds RoadPomona, NJ 08240(609) 652-1000www.atlanticare.org

Bayonne Medical Center29th Street & Avenue EBayonne, NJ 07002(201) 858-5000www.bayonnemedicalcenter.org

Bayshore Community Hospital727 North Beers StreetHolmdel, NJ 07733(732) 739-5900www.bchs.com

Bergen Regional Medical Center230 E. Ridgewood AvenueParamus, NJ 07652(201) 967-4000www.bergenregional.com

Cape Regional Medical CenterTwo Stone Harbor BoulevardCape May Court House, NJ 08210(609) 463-2000www.caperegional.com

Capital Health Regional MedicalCenter750 Brunswick AvenueTrenton, NJ 08638(609) 394-6000www.capitalhealth.org

Capital Health System at MercerOne Capital WayPennington, NJ 08534-0534800-637-2374www.capitalhealth.org

CentraState Medical Center901 West Main StreetFreehold, NJ 07728(732) 431-2000www.centrastate.com

Chilton Memorial Hospital97 West ParkwayPompton Plains, NJ 07444(973) 831-5000www.chiltonmemorial.org

Christ Hospital176 Palisade AvenueJersey City, NJ 07306(201) 795-8200www.christhospital.org

Clara Maass Medical CenterOne Clara Maass DriveBelleville, NJ 07109(973) 450-2000www.sbhcs.com/hospitals/

clara_maass

Community Medical Center99 Route 37 WestToms River, NJ 08755(732) 557-8000www.sbhcs.com/hospitals/

community_medical

Cooper Hospital/University Medical CenterOne Cooper PlazaCamden, NJ 08103(856) 342-2000www.cooperhealth.org

75A Consumer Report

Section 6New Jersey General Acute Care Hospitals

Deborah Heart and Lung Center200 Trenton RoadBrowns Mills, NJ 08015(609) 893-6611www.deborah.org

East Orange General Hospital300 Central AvenueEast Orange, NJ 07018(973) 672-8400www.evh.org

Englewood Hospital andMedical Center350 Engle StreetEnglewood, NJ 07631(201) 894-3000www.englewoodhospital.com

Hackensack University Medical Center30 Prospect AvenueHackensack, NJ 07601(201) 996-2000www.humed.com

Hackettstown Regional Medical Center651 Willow Grove StreetHackettstown, NJ 07840(908) 852-5100www.hch.org

Hoboken University MedicalCenter308 Willow AvenueHoboken, NJ 07030(201) 418-1000www.hobokenumc.com

Holy Name Hospital718 Teaneck RoadTeaneck, NJ 07666(201) 833-3000www.holyname.org

Hunterdon Medical Center2100 Wescott DriveFlemington, NJ 08822(908) 788-6100www.hunterdonhealthcare.org

Jersey City Medical Center355 Grand StreetJersey City, NJ 07302(201) 915-2000www.libertyhealth.org

Jersey Shore University MedicalCenter1945 Route 33Neptune, NJ 07753(732) 775-5500www.meridianhealth.com

JFK Medical Center65 James StreetEdison, NJ 08818(732) 321-7000www.jfkmc.org

Kennedy Memorial Hospitals–UMC Cherry Hill Division2201 Chapel Avenue WestCherry Hill, NJ 08002(856) 488-6500www.kennedyhealth.org

Kennedy Memorial Hospitals–UMCStratford Division18 East Laurel RoadStratford, NJ 08084(856) 346-6000www.kennedyhealth.org

Kennedy Memorial Hospitals–UMCWashington Twp. Division435 Hurffville-Cross Keys RoadTurnersville, NJ 08012(856) 582-2500www.kennedyhealth.org


New Jersey General Acute Care Hospitals

Newark Beth Israel Medical Center201 Lyons AvenueNewark, NJ 07112(973) 926-7000www.sbhcs.com/hospitals/

newark_beth_israel

Newton Medical Center175 High StreetNewton, NJ 07860(973) 383-2121www.nmhnj.org

Ocean Medical Center425 Jack Martin BoulevardBrick, NJ 08724(732) 840-2200www.meridianhealth.com

Our Lady of Lourdes MedicalCenter1600 Haddon AvenueCamden, NJ 08103(856) 757-3500www.lourdesnet.org

Overlook Hospital99 Beauvoir AvenueSummit, NJ 07902(908) 522-2000www.atlantichealth.org

Palisades Medical Center of New York Presbyterian Healthcare System7600 River RoadNorth Bergen, NJ 07047(201) 854-5000www.palisadesmedical.org

Raritan Bay Medical Center–Old Bridge DivisionOne Hospital PlazaOld Bridge, NJ 08857(732) 360-1000www.rbmc.org

Kimball Medical Center600 River AvenueLakewood, NJ 08701(732) 363-1900www.sbhcs.com/hospitals/

kimbal_medical

Lourdes Medical Center of Burlington County218 Sunset RoadWillingboro, NJ 08046(609) 835-2900www.lourdesnet.org

Meadowlands Hospital Medical Center55 Meadowlands ParkwaySecaucus, NJ 07096(201) 392-3100www.libertyhealth.org

Memorial Hospital of SalemCounty310 Woodstown RoadSalem, NJ 08079(856) 935-1000www.mhschealth.com

Monmouth Medical Center300 Second AvenueLong Branch, NJ 07740(732) 222-5200www.sbhcs.com/hospitals/

monmouth_medical

Morristown Memorial Hospital100 Madison AvenueMorristown, NJ 07962(973) 971-5000www.atlantichealth.org

Mountainside Hospital1 Bay AvenueMontclair, NJ 07042(973) 429-6000www.mountainsidenow.org

77A Consumer Report

Raritan Bay Medical Center–Perth Amboy Division530 New Brunswick AvenuePerth Amboy, NJ 08861(732) 442-3700www.rbmc.org

Riverview Medical CenterOne Riverview PlazaRed Bank, NJ 07701(732) 741-2700www.meridianhealth.com

Robert Wood Johnson University HospitalOne Robert Wood Johnson PlaceNew Brunswick, NJ 08901(732) 828-3000www.rwjuh.edu

Robert Wood Johnson University Hospital at HamiltonOne Hamilton Health PlaceHamilton, NJ 08690(609) 586-7900www.rwjhamilton.org

Robert Wood Johnson University Hospital at Rahway865 Stone StreetRahway, NJ 07065(732) 381-4200www.rwjuhr.com

Shore Memorial Hospital1 East New York AvenueSomers Point, NJ 08244(609) 653-3500www.shorememorial.org

Somerset Medical Center110 Rehill AvenueSomerville, NJ 08876(908) 685-2200www.somersetmedicalcenter.com

South Jersey Healthcare RegionalMedical Center1505 West Sherman AvenueVineland, NJ 08360(856) 641-8000www.sjhealthcare.net

South Jersey Hospital–Elmer501 West Front StreetElmer, NJ 08318(856) 363-1000www.sjhealthcare.net

Southern Ocean Medical Center1140 Route 72 WestManahawkin, NJ 08050(609) 597-6011www.southernoceanmedicalcenter.com

Saint Barnabas Medical Center94 Old Short Hills RoadLivingston, NJ 07039(973) 322-5000www.sbhcs.com/hospitals/

saint_barnabas

St. Clare’s Hospital–Denville25 Pocono RoadDenville, NJ 07834(973) 625-6000www.saintclares.org

St. Clare’s Hospital–Dover400 West Blackwell StreetDover, NJ 07801(973) 989-3000www.saintclares.org

St. Clare’s Hospital–Sussex20 Walnut StreetSussex, NJ 07461(973) 702-2600www.saintclares.org

St. Francis Medical Center601 Hamilton AvenueTrenton, NJ 08629(609) 599-5000www.stfrancismedical.com


St. Joseph’s Hospital and Medical Center703 Main StreetPaterson, NJ 07503(973) 754-2000www.stjosephshealth.org

St. Joseph’s Wayne Hospital224 Hamburg TurnpikeWayne, NJ 07470(973) 942-6900www.stjosephshealth.org

St. Mary’s Hospital (Passaic)350 BoulevardPassaic, NJ 07055(973) 365-4300www.smh-passaic.com

St. Michael’s Medical Center111 Central AvenueNewark, NJ 07102(973) 877-5000www.smmcnj.org

St. Peter’s University Hospital254 Easton AvenueNew Brunswick, NJ 08901(732) 745-8600www.saintpetersuh.com

Trinitas Hospital225 Williamson StreetElizabeth, NJ 07207(908) 994-5000www.trinitashospital.com

UMDNJ–University Hospital150 Bergen StreetNewark, NJ 07103(973) 972-4300www.theuniversityhospital.com

Underwood–Memorial Hospital509 N. Broad StreetWoodbury, NJ 08096(856) 845-0100www.umhospital.org

University Medical Center atPrinceton253 Witherspoon StreetPrinceton, NJ 08540(609) 497-4000www.princetonhcs.org

Valley Hospital223 North Van Dien AvenueRidgewood, NJ 07450(201) 447-8000www.valleyhealth.com

Virtua–Memorial Hospital of Burlington County175 Madison AvenueMount Holly, NJ 08060(609) 267-0700www.virtua.org

Virtua–West Jersey Hospital Berlin100 Townsend AvenueBerlin, NJ 08009(856) 322-3000www.virtua.org

Virtua–West Jersey HospitalMarlton90 Brick RoadMarlton, NJ 08053(856) 355-6000www.virtua.org

Virtua–West Jersey HospitalVoorhees101 Carnie BoulevardVoorhees, NJ 08043(856) 325-3000www.virtua.org

Warren Hospital185 Roseberry StreetPhillipsburg, NJ 08865(908) 859-6700www.warrenhospital.org

Welcome to the New Jersey 2011 Hospital Performance Report, the New Jersey Department ofHealth and Senior Services eighth annual report on the quality of care in New Jersey hospitals.

Improving patient safety and ensuring high quality health care are top priorities of the Department ofHealth and Senior Services. All of our licensed health care facilities strive every day to reducemedical errors and healthcare-associated infections (HAIs) and to ensure that every patient receivesthe highest standards of care. Educating consumers about the performance of the facilities where theyreceive care is equally important because it empowers them to make informed decisions.

Closely following the federal government’s yearly expansion of quality measures, the Department hasadded the following measures to this year’s report:D A Surgical Care Improvement Project (SCIP) measureD Three HAI measures:

l Catheter-Associated Urinary Tract Infection (CAUTI) l Two Surgical Site Infection (SSI) measures: SSI after Coronary Artery Bypass Graft

(CABG) Surgery, and SSI after Abdominal Hysterectomy

The report still contains the same measures for: D Recommended Care: heart attack, pneumonia, surgical care improvement project (SCIP) and

heart failure D 12 Patient Safety Indicators (PSI) mandated by law, and D HAI measure for Central Line-Associated Blood Stream Infection (CLABSI), also required by

legislation

All the measures in this report are based on scientific evidence and research performed at thenational level. The data is from 2010 except for the two new SSIs, which are based on 2009 data.

The Quality Improvement Advisory Committee (QIAC) is instrumental in developing this report andprovides guidance to the Department on quality initiatives. QIAC members, who are leaders fromthe New Jersey hospital industry and health care providers, volunteer their energy and skills to advisethe Department on high quality health care programs. These programs have helped position NewJersey in the forefront of other states.

For more data, consumer tips and other health care information, visit our web site atwww.nj.gov/health/hpr. Learn about: D How to prevent HAIs while in the hospital D What you can do before having surgery to help prevent medical errors, and D Tips on how to choose or locate a doctor in New Jersey

I hope you find the report useful. Please feel free to send us your feedback on the report or the website at [email protected].

A Message

For questions about this report, please contact:

Office of the Commissioner Health Care Quality Assessment (HCQA) New Jersey Department of Health and Senior Services P.O. Box 360 Trenton, New Jersey 08625-0360

You can also reach HCQA by phone at (800) 418-1397.

Find more information on our web site at www.nj.gov/health/hpr. The site allows you tochoose hospitals to compare by hospital name, condition or county. In addition to themeasures included in this report, the web site also includes mortality measures forCoronary Artery Bypass Graft (CABG) surgery; mortality for Inpatient Quality Indicators(IQIs) for heart attack, pneumonia, heart failure, and stroke; and scores for outpatientRecommended Care measures. The web site also contains an extensive list of resourcesand additional patient safety tips on how to prevent medical errors.

Portions of this report rely on material developed by the US Department of Health andHuman Services, Centers for Medicare and Medicaid Services, Centers for DiseaseControl and Prevention; the Agency for Healthcare Research and Quality, and the JointCommission.

Other reports produced by HCQA and found at the web site:

Cardiac Surgery in New JerseyInpatient Quality IndicatorsBariatric Surgery in New JerseyPrevention Quality IndicatorsPatient Safety IndicatorsHealthcare-Associated Infections

We would like to thank the following people for

their contributions to this report:

Cynthia Kirchner, Director, Quality Improvement

Emmanual Noggoh, Director

We would also like to thank the followingpeople for the graphic design, the editing

and the printing of this report:

Jan ApplebaumSue CarsonJames Wisniewski Markos Ezra

Priya Bhatia FoxLetitia Holloway-OwensJianping Huang

Juana JacksonMarcia JaffeAbate Mammo

Mary E. O’Dowd, MPHCommissionerDepartment of Health and Senior Services

From the Commissioner

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